
Gass 
Book 






CoEyiigM'N". 



COPYRIGHT DEPOSIT. 



PRACTICAL GYNECOLOGY 



MONTGOMERY 



Practical Gynecology 



A COMPREHENSIVE TEXT- BOOK 
FOR STUDENTS AND PHYSICIANS 



BY 



E. E. iVlONTGOMERY, M.D., LL.D. 

PROFESSOR OF GYNECOLOGY, JEFFERSON MEDICAL COLLEGE ; GYNECOLOGIST TO THE JEFFERSON MEDICAI 

COLLEGE AND ST. JOSEPH'S HOSPITALS ; CONSULTING GYNECOLOGIST TO THE PHILADELPHIA 

LYING IN CHARITY AND THE KENSINGTON HOSPITAL FOR WOMEN 



Second IRevtseb lEMtton 



WITH FIVE HUNDRED AND THIRTY-NINE ILLUSTRATIONS, THE GREATER 
NUMBER OF WHICH HAVE BEEN DRAWN AND ENGRAVED SPECIALLY 
FOR THIS WORK. FOR THE MOST PART FROM ORIGINAL SOURCES 



PHILADELPHIA 

BLAKISTON'S SON & CO. 

I0I2 WALNUT STREET 
1903 



THE LIBRARY OF I 
CONGRESS, 1 

Two Copies Recaivexi | 

OCT 13 1903 

Copyright ti.tiy f 
CLAlfeS ^ KXc. No 
COPY \S. I 



^ Cof 
CLASS 



y^ 



Copyright, 1903, by P. Blakiston's Son & Co. 



WM. F. FELL COMPANY 

:i.ECT ROT Y PE RS, PRINTERS 

PHILADELPHIA, PA. 



TO 

2»r. m. lb. Marker, 

MY CONSCIENTIOUS INSTRUCTOR AS QUIZ = MASTER AND HOSPITAL CHIEF, 
AND MY GENEROUS FRIEND, 

THIS BOOK IS RESPECTFULLY DEDICATED. 



PREFACE TO THE SECOND EDITION 



In presenting a second edition of this work, I desire to express 
my sincere gratification over the generous and flattering recep- 
tion the first edition has obtained from the medical press and 
the profession. 

Many changes have been made in the arrangement of the 
different divisions which experience has led me to believe will 
prove of benefit to the student. Alalformations are confined 
to congenital conditions, while the lesions of parturition are 
treated under the designation of Traumatisms. Disorders of 
the Fallopian tube and the ovary are more specifically treated 
in Inflammation. The specific treatment of the various de- 
viations is discussed in close relation with each subject. The 
division comprising genital tumors has been extensively changed 
in the consideration of myomata and malignant growths. 

It has been my purpose in the entire revision to increase the 
usefulness of the work to the student by treating, in closer detail, 
the later operative procedures, and in order to accomplish this the 
greater part of the work has been rewritten, which has added 
some seventy pages. The illustrations have been increased in 
number and many of them redraw^n. New illustrations made 
from material secured from my own practice have been largely 
substituted for the microscopic drawings of the former edition. 

I here take occasion to express my thanks to Mr. H.J. Shan- 
non for the care and painstaking skill with which he has cor- 
rected many of the old drawings and constructed several new 
ones, notably those illustrating the Doyen operation for uterine 
myomata; to Miss S. L. Clark for drawings of microscopic sec- 
tions from which the following illustrations were prepared, 
figures 42 a and b, 113, 117, 119, 120, 282, 285, 286, 288, 292, 
293, 482, 483, 499, 500, 501, 515 ; to Miss Karin M. Hall for draw- 
ings for figures 287, 296, 297; to Professor W. M. L. Coplin, M.D., 



Vlll PREFACE TO THE SECOND EDITION. 

for his kind supervision of the preparation of the microscopic 
drawings and for many valuable suggestions; to Drs. J. M. 
Fisher, John C. DaCosta, Wilmer Krusen, and C. P. Noble for 
the loan of specimens from which illustrations were prepared. 

I am indebted to Dr. P. Brooke Bland for the preparation of 
the slides from which the microscopic illustrations were made, for 
correction of the manuscript, and for assistance with the index ; to 
Miss E. A. Cantner for the rearrangement and preparation of the 
index and table of contents. The publishers deserve my un- 
stinted praise for their generous expenditure for redrawing the 
old and in the preparation of new illustrations, and for their 
purpose to present the work in an attractive form. 

It is my sincere hope that this edition shall render the phy- 
sician more efficient in lessening the ills of women and adding 
comfort and pleasure to their lives. 

Philadelphia, September 15, iQOj. 



PREFACE TO FIRST EDITION 



I will offer no apology for presenting an additional text -book 
upon gynecology. 

This work has been under consideration for the last fifteen 
years, and much of it has been several times rewritten. An 
effort has been made to make it a comprehensive work upon the 
subject, giving the experience and methods of the most careful 
men, while my own experience has been utilized to indicate that 
which I have found most useful and worthy of acceptance. 

Each general subject is considered with reference to its influ- 
ence upon the entire genital tract, and the work is divided into 
sections rather than chapters. This course, although a departure 
from the ordinary text-book arrangement, is that which expe- 
rience has demonstrated to be most effective in impressing the 
subject upon the student, and would seem to me preferable to 
him who uses the book to refresh his knowledge upon any par- 
ticular subject. The illustrations are arranged solely with the 
purpose of rendering clear the text and to promote the work of 
diagnosis and treatment. For their excellence and character I 
am greatly indebted to the generosity of the publishers and to 
the skill and patience of their artists, Messrs. Shannon and Von du 
Lancken. To the kindly oversight of Dr. Robert L. Dickinson 
is due much of the exactness of the drawings. Acknowledgment 
is due i\Iiss Eleanor A. Cantner for her ability in the preparation 
of preliminary sketches and of the index. 

Should it be the means of lightening the work of the student, 
of making more clear the pathway of the busy practitioner, and, 
most of all, of benefiting suffering women through improved 
methods of diagnosis and treatment, I shall feel well repaid for 
the many days and nights of labor which it has cost 

The Author. 

Philadelphia. Atigust, igoo. 



LIST OF CONTENTS 



INTRODUCTION. 

SECTION. PAGE. 

1. Definition and Antiquity, 17 

2. Theories, 17 

3. Foundation, 17 

4. Purpose, 17 

5. Difficulties in Study, 18 

6. Observation, 18 

7. Exercise of Judgment, 19 

8. Value of Notes, ig 

9. History, 19 

DIAGNOSIS. 

10. Subjective Symptoms, 20 

11. Causes of Error, 20 

12. Method of Procedure, 20 

13. General Symptoms, 20 

14. Visceral Neuralgias, 21 

15. Neuralgia, 21 

16. Motor and Sensory Paralysis, 21 

17. Disorders of Nutrition 21 

18. Chlorosis, 21 

19. Anemia, 21 

20. Local Symptoms, 22 

21. Rectal Reflexes, 22 

22. Vesical Reflexes, 23 

23. Genital Symptoms 23 

24. Hemorrhage, 24 

25. Pain, 24 

26. Seats of Pain, 24 

27. The Iliac Pain, 25 

28. Lumbar Pain 25 

29. Lateral Pain, 25 

30. Hypogastric Pain, 25 

31. The Accessory Seats of Pain, 25 

32. The Anal or Perineal Pain 25 

33. Vaginal Pain, 26 

34. Pelvic Pain, 26 

35. Leukorrhea 26 

36. The Secretion from the Fallopian Tubes and Cavity of the Uterus,-- 26 

37. The Secretion of the Vagina and Vulva, 26 

38. Catarrhal Discharge, 26 

39. Origin of Discharge, 26 

40. Discharge Simulating Abscess, 27 

41. Other Sources for Purulent Discharges, 2-] 

42. Cervical Discharge, 27 

43. Vaginal Discharge, 27 

44. Eftect of Age upon the Discharge, 27 

45. Physical Signs, 28 

46. Senses Employed 28 

47. Examination, 28 

48. Pelvic Examination, 28 

xi 



Xll LIST OF CONTENTS. 

SECTION. PAGE. 

49. Abdominal Examination, 28 

50. Preliminaries, 28 

51. Positions, 29 

52. The Dorsal Position, 29 

53. The Lateral Position, 29 

54. The Semiprone or Sims' Position, 30 

55. The Genupectoral Position, 31 

56. The Trendelenburg Position, 31 

57. The Erect Position, 32 

PELVIC EXAMINATION. 

58. Inspection, 32 

59. Simple Touch, 32 

60. Preparation, 32 

61. Procedure, ^^ 

62. Bimanual Procedure, 35 

63. Difficulties, 35 

64. Virgins, ^6 

65. Rectal Touch, 36 

66. Simon's Method, s^ 

67. Precautions, ^8 

68. Instrumental Examination, 39 

69. Probes, 39 

70. Precautions. 41 

71. Speculum, 42 

72. The Tubular Speculum, 42 

73. Valvular Speculum, 43 

74. The Univalve or Duck-bill Speculum, 45 

75. Uterine Fixation and Downward Traction, 47 

76. Dilatation of the Uterus, 48 

77. Dilatation by Tents, 48 

78. Divulsion, 50 

79. Gradual Dilatation, 50 

80. Incision of the Cervix, 51 

81. Complete Bilateral Incision of the Cervix, 52 

82. Dilatation by Gauze Packing, 52 

83. Cureting, ____ 53 

84. Microscopic Examination, 53 

85. Microscope, 53 

86. Material, 54 

87. Methods, 54 

88. Failure, 60 

89. Bacteriologic Cultures, 60 

90. The Gonococcus of Neisser, 60 

91. Staphylococcus Pyogenes Aureus, : 62 

92. Streptococcus Pyogenes, 62 

93. The Bacillus Coli Communis, 63 

94. The Bacillus Tuberculosis, 63 

95. Exploration of the Urethra, Bladder, and Ureters, 64 

ABDOMINAL EXAMINATION. 

96. Preliminaries, 67 

97. Inspection, 67 

98. Palpation, 68 

99. Difficulties, 69 

100. Percussion, 69 

10 1. Auscultation, 69 

102. Exploratory Puncture, 70 

103. Tapping, or Paracentesis Abdominis, 70 

104. Aspiration, 71 

105. Exploratory Incision, 72 



LIST OF CONTENTS. Xlll 



SECTION. THERAPEUTICS. page. 

io6. Classification, 72 

107. Extension, __ 72 

108. Infection, 72 

109. Terms, '. 72 

no. Sterilization Methods, 73 

111. Sterilization of Instruments, 73 

112. Sponges, 74 

113. Ligature and Suture Material, 76 

114. Dressings, 77 

115. Operator and Assistants, 78 

116. Precautions, 79 

117. Room and Environment, 79 

118. Examination and Preparation of Patient, 79 

119. Special Preparation, 81 

120. Irrigating Tubes, 81 

121. Gauze, 82 

122. Antisepsis of the Cervix and Uterine Cavity, 82 

123. The Use of Tents, 83 

124. Abdominal Section, 83 

125. Indications for Anesthesia, 84 

126. Agents Employed, 84 

127. Administration, 86 

128. Local Anesthesia, 86 

129. Preliminary Details of Operation, 88 

130. Arrangement, 88 

131. Positions of Operator and Assistants, 88 

132. Clothing of Patient, 89 

133. Incision, 90 

134. Adhesions, 91 

135. Toilet of the Peritoneum, 91 

136. Drainage, 92 

137. Objections to Drainage, 93 

138. Gauze Drain, 94 

139. Where Placed, 95 

140. Postural Drainage, 95 

141. Closure of the Wound, 95 

142. Dressing, 96 

143. Postoperative Treatment, 97 

144. Precautions in the Use of the Hypodermic Syringe, 98 

145. Catheterization, 98 

146. Comfort of Patient, 98 

147. Vomiting, 99 

148. Tympanites, 100 

149. Shock, loi 

150. Anodynes, loi 

151. Internal Hemorrhage, loi 

152. Removal of Sutures, loi 

153. When Permitted to Get Up, 102 

154. Plastic Operations, 102 

MEDICAL TREATMENT. 

155. General Treatment, 102 

156. Specific Remedies, 103 

157. Rest and Exercise, 104 

LOCAL THERAPEUTICS. 

158. Baths, T05 

159. Douche, 105 

160. External Applications, 106 

161. Counterirritants, 106 



Xiv LIST OF CONTEl^TS. 

SECTION. PAGE. 

162. Bloodletting, 106 

163. Local Applications, 106 

164. Various Agents, 107 

165. Astringents, 108 

166. Caustics, 108 

167. Tampons, 108 

168. Massage, 109 

169. Pelvic Massage 109 

ELECTRICITY. 

170. Forms, iii 

171. Franklinism, iii 

172. Galvanism, iii 

173. Apparatus for Application, 112 

174. Method of Procedure, 113 

175. Indications, 114 

176. Contraindications, 114 

177. Faradic, 114 

178. Sinusoidal, 115 

179. Rontgenic, 116 

180. Finsen Light, 117 

181. Electrocautery and Light, 117 

EMBRYOLOGY AND ANATOMY OF THE GENITO-URINARY 
ORGANS OF THE WOMAN. 

182. Development of the Genito-urinary Organs, 118 

183. Division of the Genitalia, 121 

184. The External Genital Organs, 121 

185. The Mons Veneris, 121 

186. The Labia Majora, 121 

187. The Labia Minora, 121 

188. The Clitoris, 123 

189. The Vestibule, 124 

190. The Hymen, 125 

191. The Fourchet, 127 

192. The Muscles of the Perineum, 127 

193. The Perineal Fascia, 129 

194. Pelvic Diaphragm, 132 

195. Perforations, 133 

196. Internal Genitalia, 133 

197. The Vagina, 133 

198. The Uterus, 140 

199. The Fallopian Tubes, 145 

200. Ovaries, 147 

201. The Parovarium, 153 

202. Urinary Organs and Rectum, 153 

203. The Urethra, 153 

204. The Bladder, 154 

205. The Ureters, 156 

206. The Rectum, 156 

207. Pelvic Peritoneum, 159 

208. Pelvic Connective Tissue, 162 

209. The Vascular Supply, 163 

210. The Lymphatic System, 170 

211. Consideration of the Pelvic Organs and Structure Studied as a Whole, 173 

PHYSIOLOGY. 

212. Functions, i74 

213. Puberty i74 

214. Nubility, i75 



LIST OF CONTENTS. XV 

SECTION. PAGE. 

215. Menstruation and Ovulation. 175 

216. Menopause, 178 

217. Copulation, 180 

218. Fecundation, iSo 

MALFORMATIONS. 

219. Classification; Definition, 181 

220. Bifidities, 181 

221. The Degrees of Division, 181 

222. Double Uterus, 182 

223. Unequal Development of the Two Sides, 183 

224. Absent Uterus, 185 

225. A Rudimentary Uterus, 185 

226. Fetal and Infantile Uteri, 186 

227. Congenital Prolapsus Uteri, 188 

228. Accessory or Trifid Uteri 188 

229. Absent or Rudimentary Tubes, 188 

230. Accessory Tubal Ostia, 188 

231. Anomalies in Length, 188 

232. Absent or Rudimentary Ovaries, 188 

233. Supernumerary Ovaries, 188 

234. Accessory or Constricted Ovaries, 189 

235. Displacements, 189 

236. Defects of Round or Broad Ligaments, 189 

237. Complete Absence or Rudimentary Development of the Vagina, __ 189 

238. Unilateral Vagina, 193 

239. Double Vagina, 193 

240. Atresia of the Genital Canal, 194 

241. Lateral Atresia, 197 

242. Absence of the Vulva, 198 

243. Infantile Vulva, 198 

244. Defects in Nymph^e, 198 

245. Defects of the Clitoris, 199 

246. Defects of the Hymen, 200 

247. Hermaphroditism, 200 

248. Gynandria, 201 

249. Androg}ma, 202 

250. Atresia of the Urethra and Vagina, 203 

251. Hypospadias, 203 

252. Epispadias, 203 

253. Duplication of the Bladder, 206 

254. Open Urachus, 206 

255. Irregular Exit of Ureter, 206 

256. Abnormal Communications, 206 

TRAUMATISMS. 

257. Injuries of the Genital Organs, 207 

258. External Violence, 207 

259. Coition, 208 

260. Parturition, 209 

261. Injuries of the Body of the Uterus, 210 

262. Injuries of the Cervix Uteri, , 211 

263. Symptoms of Laceration of the Cervix 212 

264. Diagnosis, 212 

265. Treatment, 214 

266. The Presence of Endometritis, 214 

267. Trachelorrhaphy, 216 

268. Amputation of the Cervix, 218 

269. After-treatment, 219 

270. Lacerations of the Vagina, 220 



XVI LIST OF CONTENTS. 

SECTION. PAGE. 

271. Fistulae, 221 

272. Etiology, 221 

273. Symptoms, 222 

274. Diagnosis, 222 

275. Prognosis, 223 

276. Treatment, 224 

277. Cauterization, 224 

278. Preliminary Treatment, 224 

279. Vesicovaginal Fistula, 225 

280. Flap-splitting, 226 

281. Flap Formation, 231 

282. After-treatment, 233 

283. Closure of the Vagina ; Colpocleisis ; Episiostenosis , 233 

284. Urethrovaginal Fistula, 236 

285. Vesicp-uterine Fistula, 236 

286. Hysterostenosis or Hysterocleisis, 238 

287. Vesico-uterovaginal (Cervical) Fistula, 238 

288. Uretero vaginal-ureterocervical Fistulae , 239 

289. Accidents of the Operation and Results, 243 

290. Rectovaginal Fistula, 245 

291. An Anovulvar Fistula, 246 

292. Preliminary and After-treatment, 247 

293. Entero vaginal Fistula, 247 

294. Lacerations of the Pelvic Floor, 248 

295. Causes, 249 

296. Degree or Extent, -. 250 

297. The Results, 251 

298. Treatment, 252 

299., By Primary Operation, 253 

300. The Advantages of the Primary Procedure , 254 

301. Contraindications, 255 

302. The Intermediate Operation, 255 

303. Secondary Operation, 256 

304. After-treatment, 280 

305. Choice of Operation, 282 

INFLAMMATIONS. 

306. The Recognition of the Development of the Genital Tract, 283 

307. Micro-organisms as a Cause, 284 

308. Natural Protection against Infection, 284 

309. How Immunity is Lost, 284 

310. Inflammation and Its Varieties, 284 

311. The Causes of Inflammation, 285 

312. Characteristics of Inflammation, 286 

313. Classification of Inflammation, 287 

314. Vulvitis and Its Varieties, 288 

315. Causes, 288 

316. Vulvitis, Simple or Catarrhal, : 289 

317. Follicular Vulvitis, 289 

318. Venereal Vulvitis, 289 

319. Eruptive Diseases of the Vulva, ^ 291 

320. Phlegmonous Vulvitis, 292 

321. Diphtheric Vulvitis, 292 

322. Diagnosis of Inflammatory Disease of the Vulva, 292 

323. Treatment, 293 

324. Edema and Gangrene, 295 

325. Bartholinitis, 295 

326. Pruritus Vulvas 298 

327. Kraurosis Vulvas, . 300 

328. Vaginismus, 301 

329. Vulvo- vaginitis, 303 



LIST OF CONTENTS. XVll 

SECTION. PAGE. 

330. Vaginitis, Elytritis, or Colpitis, 304 

331. Varieties, -. 306 

332. Pathology, 306 

333. Etiology, 307 

334. Symptoms, 308 

335- Diagnosis, _ 308 

336. Prognosis, 309 

337. Treatment, _-_ 309 

338. Urethritis, 310 

339. Hyperemia, 311 

340. Acute Catarrhal Urethritis, 312 

341. Chronic Catarrhal Urethritis, 312 

342. Follicular Inflammation, 312 

343. Ulceration, 313 

344. Vesico-urethral Fissure, 314 

345. Diagnosis of Urethral Inflammations, 314 

346. Treatment of Urethral Inflammations 315 

347. Cystitis, 317 

348. Symptoms of Acute Cystitis, 318 

349. Symptoms of Chronic Cystitis, 319 

350. Cystitis of Gonorrheal Origin 319 

351. Tubercular Cystitis, 319 

352. Diagnosis of Cystitis, 320 

353. The Prognosis of Cystitis, 323 

354. Treatment, 324 

355. Ureteritis, 328 

356. Acute Ureteritis, 328 

357. Chronic Ureteritis, 329 

INFLAMMATION OF THE CERVIX AND BODY OF THE 

UTERUS. 

358. Classification, 330 

359. Endocervicitis ; Chronic Cervical Catarrh, 331 

360. Causes, 334 

361. Symptoms, 334 

362. Physical Signs, 335 

363. Diagnosis, 335 

364. Prognosis, 336 

365. Treatment, ^^6 

366. Acute Metritis and Endometritis, 339 

367. Pathologic Alterations, 339 

368. Varieties and Their Source, 340 

369. Symptoms, 340 

370. Diagnosis, 342 

371. Prognosis, _ 344 

372. Treatment, 344 

373. Chronic Endometritis, 348 

374. Symptoms, 349 

375. Diagnosis, 351 

376. Treatment, 353 

377. Chronic Metritis, 355 

378. Etiolog>^ 356 

379. Symptoms, 357 

380. Physical Signs and Diagnosis, 359 

381. Course and Prognosis, 360 

382. Treatment, 360 

383. Inflammation of the Fallopian Tube, 365 

384. Symptoms, 371 

385. Diagnosis, 372 

386. Prognosis, 374 

387. Inflammation of the Ovary, 374 



XVlll LIST OF CONTENTS. 

SECTION. PAGE. 

388. Symptoms, 378 

389. Diagnosis, 379 

390. Treatment of Inflammation of the Appendages, 379 

391. Pelvic Inflammation, 384 

392. Varieties, 384 

393. Pelvic Cellulitis, Parametritis, or Periuterine Phlegmon, 384 

394. Etiology, 386 

395. Symptoms, 387 

396. Physical Signs, 387 

397. Diagnosis, ^ 390 

398. Prognosis, 392 

399. Treatment, 393 

400. Pelvic Peritonitis, Perimetritis, Perisalpingitis, or Perioophoritis, 394 

401. Etiology, 394 

402. Pathologic Anatomy, 398 

403. Symptoms, 400 

404. Diagnosis, 402 

405. Prognosis, 402 

406. Treatment, 403 

DEVIATIONS OF THE PELVIC ORGANS. 

407. Changed Relations of Structures of Vulva, 421 

408. Physiologic Movements of the Uterus and the Forces by which it is 

Sustained, 421 

409. Pathologic Changes and What Constitute Them, 424 

410. Classification of Displacements, 425 

411. Ascent, 426 

412. Diagnosis, 427 

413. Descent, or Prolapsus, 428 

414. Etiology, 429 

415. Symptoms, 431 

416. Diagnosis, 435 

417. Prognosis, 439 

418. Treatment, 442 

419. Urethrocele, 452 

420. Dislocation of the Uterus, 453 

421. Diagnosis, 454 

422. Torsion, 454 

423. Anteversion, 454 

424. Etiology, 455 

425. Symptoms, 455 

426. Diagnosis, 455 

427. Treatment, 456 

428. Retroversion, 457 

429. Etiology, 458 

430. Symptoms, 459 

431. Diagnosis, 459 

432. Lateral Version, 459 

433. Anteflexion, 459 

434. Etiology, 461 

435. Symptoms, 462 

436. Diagnosis, 462 

437. Treatment, 463 

438. Retroflexion, 469 

439. Etiology, 470 

440. Symptoms, 47° 

441. Diagnosis, 471 

442. Treatment of Retroversion and Retroflexion, 473 

443. Lateral Flexion, 49^ 

444. Complications Associated with Displacements, 496 

445. Prognosis of Displacements, 497 



LIST OF CONTEXTS. XIX 

SECTION. ■ PAGE. 

446. General Treatment, 497 

447. Summary, 499 

448. Inversion of the Uterus, 500 

449. Etiology, 502 

450. Symptoms, 503 

451. Diagnosis, 504 

452. Treatment, i-_ 507 

453. Displacements of the Appendages, 512 

454. Symptoms, 514 

455. Diagnosis, 515 

456. Treatment, 516 

GENITO-URINARY HEMORRHAGE AND ECTOPIC GESTATION. 

457. Hemorrhage a Symptom, 517 

458. Site and Varieties, 517 

459. Hematuria and Its Causes, 517 

460. Symptoms and Diagnosis, 518 

461. Treatment, 519 

462. Genital Hemorrhage or Bleeding, 519 

463. Diagnosis, 520 

464. Treatment, 522 

465. Vulvar Hematoma or Hematocele, 523 

466. Vaginal Hematoma or Thrombus, 524 

467. Diagnosis, 525 

468. Treatment, 525 

469. Perititerine Hemorrhage, 526 

470. Causes, 526 

471. Symptoms, 527 

472. Extraperitoneal Hematocele. 529 

473. Symptoms, 529 

474. Diagnosis, 530 

475. Prognosis. 531 

476. Treatment, 531 

477. Extra-uterine Pregnancy, 533 

478. Causes, 533 

479. Varieties, 535 

480. Course and Progress, 537 

481. Symptoms, 547 

482. Diagnosis, 549 

483. Differential Diagnosis, 554 

484. Prognosis, 558 

485. Treatment, 559 

GENITAL TUMORS. 

486. Definition, 571 

VULVA, VAGINA, AND BLADDER. 

487. Classification, 572 

488. The Gaseous C3"sts. 572 

489. Liquid Cysts, 574 

490. Sebaceous Cysts, 574 

491. Blood Cysts, 574 

492. Erectile or Vascular Tumors. 575 

493. Varicose Veins, 577 

494. Neuroma of the Vulva. 577 

495. Simple Vegetations, 578 

496. Edema, 580 

497. Solid Tumors; Elephantiasis, 580 

498. Fibroma and Myxoma, 581 

499. Lipoma, 582 



XX LIST OF CONTENTS. 

SECTION. PAGE. 

500. An Enchondroma, 582 

501. Malignant Disease of the Vulva, 582 

VAGINA. 

502. Cysts of the Vagina, 586 

503. Fibroid Tumors and Polypi, 587 

504. Papillomata, 588 

505. Malignant Neoplasms, 588 

506. Tumors of the Bladder, ^gcf 

507. Mucous Polypi, ---- ' - 59* 

508. Myoma, _ ■ 591 

509. Carcinoma, 597 

UTERUS. 

510. Fibromyomatous Tumors, _^ 599 

511. Pathologic Anatomy, _* 600 

512. Microscopic Appearance, 602 

513. Varieties, _• 602 

514. Submucous Fibroids, 603 

515. Interstitial, Mural, or Centric Fibroid Growths, 606 

516. Subperitoneal Growths, 607 

517. Fibromyoma of the Cervix, 609 

518. Etiology, 610 

519. Symptoms, 613 

520. Diagnosis of Myomata, , 617 

521. Differential Diagnosis of Myomata, 620 

522. Alterations and Degenerations, 624 

523. Mixed Growths: Enchondroma, Sarcoma, Osteoma, and Carcinoma, 628 

524. Complications, 629 

525. (a) The Influence of the Myoma upon Conception , 631 

526. (b) Influence of Pregnancy upon the Myoma, 632 

527. (c) The Influence of the Myoma upon Pregnancy, 633 

528. (d) Influence upon Labor, 634 

529. Course and Prognosis, 634 

530. Treatment, !__ 637 

531. (a) Medical Treatment, 638 

532. (b) Electric, 641 

533. (c) Surgical, 645 

Vaginal Procedures: 

534. (i) Dilatation and Curetment of the Uterus, 646 

535. (2) Incision of the Cervix, 649 

536. (3) Incision of the Capsule, ^ 649 

537. (4) Removal of the Growth, 650 

538. (5) Ligation of the Vessels, 656 

539. (6) Hysterectomy, 657 

Abdominal Route: 

540. (7) Castration, 658 

541. (8) Ligation of the Vessels, 660 

542. (9) Myomectomy, __ 660 

543. (10) Enucleation, 661 

544. (11) Partial Hysterectomy, or Supravaginal Amputation of the 

Uterus, 66;^ 

545. (12) Panhysterectomy, 669 

546. Summary, 674 

547. Accidents during Operation, 675 

548. Causes of Death Following Hysterectomy, 679 

549. After-treatment, : 680 

550. Puerperal Tumors; Physometra 683 

551. Hydrometra, 683 

352. Hematometra, 683 



LIST OF CONTENTS. XXI 

SF.CTION. PAGE. 

553. Hydatid Cysts of the Uterus, 684 

554. Mucous Polypi of the Uterus, 684 

555/ Mahgnant Tumors, 685 

556. Classification, 686 

557. Carcinomata, 686 

558. General Pathology, 686 

559. Structure of the Stroma, 689 

560. Carcinoma of the Portio Vaginalis, 692 

561. Adenocarcinoma of the Cervix, 693 

562. Adenocarcinoma of the Uterine Body, 696 

563. Infl.uence of Carcinoma upon the Surrounding Tissues, 698 

564. Process of Extension, 699 

565. Clinical Forms, 702 

566. Etiology, ^ 704 

567. Symptoms, 706 

568. Physical Signs, 710 

569. Complications, 712 

570. Diagnosis, 715 

571. Duration of Cancer, 720 

572. Prognosis, _-^ 720 

573. Treatment, 722 

574. (A) Operable, _ 722 

575. Total Extirpation of the Uterus, 725 

576. Vaginal Hysterectomy, 729 

577. Accidents of Vaginal Total Extirpation, 736 

578. Abdominal Hysterectomy, 737 

579. Comparative Advantages of the Two Proceedings, 742 

580. The Sacral Method, 744 

581. The Perineal Method, 751 

582. The Mortality of Abdominal and Vaginal Operations, 752 

583. Duration of Recovery, 752 

584. Recurrence, 753 

585. (B) Inoperable, 756 

586. Pregnancy Complicating Carcinoma, 767 

587. Summary, 768 

588. Chorio-epithelioma Malignum, 770 

589. Endothelioma Uteri, 772 

590. Sarcoma Uteri, 773 

591. Varieties, 773 

592. Pathology 773 

593. Etiology, 778 

594. Symptoms, 779 

595. Duration, 782 

596. Diagnosis, 783 

597. Recurrence, 786 

598. Treatment, 787 

599. Treatment Following Operations for Malignant Disease, 788 



FALLOPIAN TUBES. 

600. Tumors (Benign), 789 

601. Fibroma or Myoma, 789 

602. Fibrocyst, 789 

603. Enchondromata, 790 

604. Dermoid of the Tube, 790 

605. Cysts of Small Size, 790 

606. Polypus, 791 

607. Papillomata, 791 

608. Malignant Tumors, 791 

609. Sarcoma, 792 

610. Chorio-epithelioma Malignum, 793 



XXll LIST OF CONTENTS. 



SECTION. BROAD LIGAMENTS. 



PAGE. 



6ii. Cysts of the Broad Ligament, 793 

612. Echinococcus Cysts, 794 

613. Parovarian Varicocele; Phleboliths, 795 

614. Lipomata, 795 

615. Fibroma, 795 

616. Malignant Growths, 795 

OVARIAN TUMORS. 

617. Characteristics, 796 

618. Classification, 796 

619. Small Residual Cysts. 798 

620. Simple or Follicular Cysts; Hydrops FoUiculorum, 799 

621. Cysts of the Corpus Luteum, 800 

622. Tubo-ovarian Cysts, 800 

623. Glandular Proliferating Cysts, , 801 

624. Pedicle, 802 

625. Structure, 805 

626. Papillary Proliferous Cysts, 809 

627. Dermoid Cysts, 810 

628. Parovarian Cysts, 811 

629. Solid Ovarian Tumors, 812 

630. Fibromyoma, 812 

631. Sarcoma of the Ovary, 813 

632. Carcinoma of the Ovary, 814 

633. Endothelioma of the Ovary, 814 

634. Etiology, 814 

635. Natural Progress, 815 

636. Symptoms, 816 

637. Complications, 817 

638. Degenerative Changes in the Cyst-walls, 824 

639. Diagnosis, 824 

640. Exploratory Puncture. 837 

641. Exploratory Incision, 8^8 

642. Treatment, 8^8 

643. Ovariotomy, 839 

644. Indications, 839 

645. Contraindications, 840 

646. General Considerations, 841 

647. Operation, 842 

648. Incomplete Operation, 849 

649. Rupture of the Cyst, 850 

650. Hemorrhage, 850 

651. Visceral Injuries, . 851 

652. Prognosis, 853 

653. Intestinal Complications, 854 

654. Causes of Death, 854 



Index, 857 



LIST OF ILLUSTRATIONS 



FIG. PAGE. 

1. Chadwick Table, 28 

2. Dorsal Position, 29 

3. Sims' Position. Proper Method of Holding the Speculum, 30 

4. Genupectoral Position. Organs Shown in Outline, 30 

5. Trendelenburg Position, 31 

6. Proper Position of Fingers for Examination, t,^ 

7. Half Section of the Pelvis with Patient Erect, Showing Normal Posi- 

tion of Uterus (Deaver), 34 

8. Bimanual Examination, 36 

9. Recto-abdominal Palpation, 37 

10. Recto-vagino-abdominal Palpation. Index Finger of One Hand in 

the Rectum, Thumb in the Vagina, and the Fingers of the Other 

Hand over the Abdomen, 38 

11. Rectovesical Palpation. Sound in Bladder, 39 

12. Simpson's Sound, 40 

13. Sims' Probe, 40 

14. Whalebone Probe, 40 

15. Spring Probe Covered with Rubber, 40 

16. Introduction of the Sound, 41 

17. Ferguson's Speculum, 42 

18. Milk- glass Specula, 43 

19. Nott's Speculum, 43 

20. Higbee's Specula (three sizes), 44 

21. Talley's Speculum, 44 

22. Goodell's Speculum, 44 

23. Sims' Speculum, 45 

24. Proper Method of Holding Sims' Speculum. The Cervix Brought 

into View with the Tenaculum, 45 

25. Sims' Depressor, 46 

26. Goodell's Tenaculum, 46 

27. Self -retaining Sims' Speculum, 46 

28. Simon's Retractors, 46 

29. Edebohls' Speculum, 47 

30. Edebohls' Speculum in Position, 47 

31. Double Tenaculum Forceps, 47 

32. Traction upon Uterus with Double Tenaculum during Digital Exam- 

ination by the Rectum, 48 

33. Hollow Laminaria Tent, 49 

34. Uterine Forceps — Dressing, 49 

35. Dilated Tent Showing Constriction from Internal Os (Thomas) , 49 

36. Ellinger's Dilator, 50 

37. Goodell's Modification of Ellinger's Dilator, 50 

38. Pratt's Dilators, 50 

39. The Method of Dilatation with the Graduated Bougies, 51 

40. Kuchenmeister's Scissors, 52 

41. Douche Curet, 53 

42. a. Secretion from Gonorrheal Vaginitis, Showing Gonococci, 61 

42. b. Secretion of Simple Vaginitis Showing Variotis Forms, 61 

43 . Staphylococcus Pyogenes Aureus (Coplin) , 62 

44. Streptococcus Pyogenes (Co/'/m), 62 

45. Bacillus Coli Communis {Coplin), 63 

xxiii 



XXIV LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

46. Bacillus Tuberculosis (Coplin), 63 

47. Skene's Urethroscope, 64 

48. Kelly's Specula (Urethra), 65 

49 and 50. Ureteral Catheters. Metal and Soft, 65 

51. Mouse-tooth Forceps for Cotton Pledgets, 65 

52. Kelly's Evacuator, 66 

53. Harris' Double Catheter for Obtaining Urine from Kidneys Sepa- 

rately, 66 

54. Abdomen Prepared for Examination, 67 

55. Nest of Trocars, 70 

56. Aspirator, 71 

57. Arnold Steam Sterilizer, 73 

58. Steam-pressure Sterilizer, 74 

59. Sterilizer for Boiling Instruments, 74 

60. Gauze Pads, 75 

61. Irrigating Glass Tube. Open End, 81 

62. White's Oxygen Apparatus, which can be Utilized for Anesthesia by 

Placing Anesthetic in the Bottle, 85 

63. Northrup's Apparatus for Administering a Mixture of Chloroform and 

Oxygen, 85 

64. Arrangement of Tables and Assistants in Operating Room, 89 

65. Abdominal Wall Incised; Peritoneum Picked up by Dissecting For- 

ceps, 90 

66. Peritoneum Incised, 90 

67. Scalpels, . 91 

68. Pressure Forceps, 91 

69. Dissecting Forceps — Long Bladed, 92 

70. Glass Drainage-tubes, 92 

71. Uterine Syringe for Cleansing Drainage-tube, 93 

72. Tube Forceps for Cotton Pledgets, 93 

73. Gauze Wick in Drain, 93 

74. Mikulicz Drain, 94 

75. Gauze Drain Covered with Rubber Tissue, 95 

76. Curved and Straight Needles, 96 

77. Needle Forceps, ^" 96 

78. I. Peritoneum Nearly Closed with Continuous Catgut. 2. Silkworm- 

gut Sutures through All Structures above Peritoneum. 3. 

Aponeurosis being United with Continuous Suture of Catgut, __ 97 

79. Silkworm-gut Sutures Tied, 97 

80. Butt Uterine Scarifier, 106 

81. Aluminium Uterine Applicator, 107 

82. Long Glass Pipet, ^ 107 

83. Insufflator — Straight Stem, 108 

84. Tampon, 108 

85. Position of the Fingers in Pelvic Massage, no 

86. Portable Galvanic Battery with Galvanometer, 112 

87. Intra-uterine Electrode with Movable Insulating Cover, 113 

88. Vaginal Electrodes of Different Sizes, 113 

89. Faradic Battery, 115 

90. Bipolar Uterine Electrode, 116 

91. Vaginal Electrode — Bipolar, 116 

9 2 . Human Embryo at end of Thirty-five Days (Coste) , 119 

93. Coalescence of Miiller's Duct, 120 

94, 95, and 96. Progress of Development of the Genitalia, 120 

97. Virgin Vulva: Labia not Separated (L>^a7;^r) , 122 

98. Virgin Vulva: Labia Separated, Showing the Hymen Unruptured 

(Deaver) , 123 

99. Hymen Crescens, 124 

100. Hymen Annularis, 124 

loi. Hymen Serratus, ■. 125 

102. Hymen Infundibularis, 125 

103. Hymen Biseptus, 126 



LIST OF ILLUSTRATIONS. XXV 

FIG. PAGE. 

104. Hymen Cribriformis, 126 

105. Laceration of the Hymen, 127 

106. Muscles of the Female Perineum (P^at'^r) , . 128 

107. The Under Surface of the Levator Ani Muscle (Deaver) , 132 

108. The Upper Surface of the Levator Ani Muscle (Deaver) , 134 

109. A Mesial Section: the Body Erect (Z^^a^igf) , 135 

no. A Mesial Section: the Body Recumbent, 136 

111. Arteries and Nerves of the Female Perineum (Savage) , 137 

112. Anterior Wall of Vagina Showing Columns Rugarum (By ford, after 

Savage), 138 

113. Horizontal Section of the Vagina and Urethra of an Infant, 139 

114. Median Section of Uterus from Side to Side through the Fallopian 

Tubes. Mode of Junction of Vagina and Litems (Savage), 141 

115. Virgin Uterus. Medisin Section (By ford, after Sap pey^) , 143 

116. Mucous Membrane of Uterine Body Showing Follicles (Mann), 143 

117. Section of Normal Endometrium, 144 

118. Virgin Os and Cervix (Sa/'/^f-y) , 145 

119. Section of Fallopian Tube through the Isthmus, 147 

120. Section of Tube through the Ampulla near the Isthmus, 148 

121. Section of Ovary, Showing Graafian Follicles (Wyder), 150 

122. Large Corpus Luteum in Association with an Ovarian Dermoid. Re- 

moved from an L^nmarried Woman who had Never Been Preg- 
nant (Sutton), 152 

123. Vesicovaginal Septum and Base of Female Bladder. Anatomic Re- 

lations of Ureters at Their Entrance into the Bladder. Contents 

of Alar Ligament (Savage) . 155 

124. Superior View of the Pelvic Cavity (Deaver) , 158 

125. Curved Dotted Line Shows Covering of the Anterior Uterine Wall 

by Peritoneum (Winter) , 160 

126. Posterior Surface of Uterus Showing Extent of Peritoneum: also 

Fallopian Tubes, Ovaries, and Ovarian Ligaments (Winter) , 160 

127. Vertical Transverse Section of the Pelvis, Showing Peritoneal Pouches 

(Luschka) , 161 

128. Distribution of the Uterine and Ovarian Vessels, 164 

129. Arteries of the Female Pelvic Organs (Salvage?) , 165 

130. Distribution of the Pudic Artery to the Structures of the Perineum 

(Deaver) , 166 

131. Relation of the Urethral and Vaginal Venous Plexuses with the Veins 

of the Clitoris and Bulb: The Right Side of the Pelvis Removed 
by a Section in Front, through the Pubic Body, About an Inch 
from the Symphysis, and, Behind, through Sacro-iliac Joint (Sav- 
age) , 167 

132. Veins and Erectile Venous Plexuses of the Female Pelvis (Savage) , 168 

133. Erectile Organs and Veins of the Female Perineum (Savage) , 169 

134. The Lumbo-iliac Lymphatics and Glands. Lymphatics of the 

Gravid Uterus and Appendages (Savage) , 170 

135. Nerves of the Unimpregnated Uterus with the Nerves of the Clitoris 

(Savage) 17*2 

136. Changes of Uterine Mucous Membrane during Menstruation (Wyder), 177 

137. Degrees of Division of the Genital Tract, 182 

138. Uterus Bicomis (A «xjar(i), 182 

139. Uterus Bicomis Unicollis (Am. Sys. Gyn.) , 183 

140. Uterus Bifida (Auvard), 1 183 

141. Uterus Didelphys (Am. Sys. Gyn.) , 184 

142. Uterus Unicornis (Auvard) , 184 

143. Atresia of Rudimentary Horn with an Accumulation of Menstrual 

Blood (Atcvard), 185 

144. Uterus Bipartitus or Duplex (B3//or(i) , 186 

145. Uterus Biseptus (Courty), 187 

146. Absent Vagina, 190 

147. Line of Incision for Formation of Flaps, i, 2. Flaps from Labia 

Minora which are Split and Used to Line the Vagina, 191 



XXVI LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

14S. Flaps Outlined in Fig. 147 Sutured in Place, and Denuded Surfaces 

which have Furnished Flaps to Line Posterior Wall, 192 

149. Sims' Glass Dilator, 193 

1 50. Double Vagina {Photograph taken from patient of Dr. J. M. Fisher) , 193 

151. Imperforate Hymen. 195 

152. Hematocolpos, 196 

153. Hematometra, 197 

154. Hematocolpometra, 198 

155. Enlarged Clitoris, 199 

156. Apparent Hermaphroditism — (American Journal of Obstetrics) , 201 

157. External Genital Organs of Madame Le Fort (Auvard) , 201 

158. Outline of Internal Organs of Madame Le Fort (A uvard) , 202 

159. Androgyna (Pozzi), 203 

160. Imperforate Anus. Communication between Rectum and Vagina, 204 

161. Congenital Defect of Vagina. Communication with the Rectum, 204 

162. Congenital Absence of the Urethra. Communication of Bladder 

with the Vagina, 205 

163. Communication of Rectum and Bladder with the Vagina, 205 

164 . Suprapubic. Opening of Vagina and Urethra, 206 

165. Knives for Denudation, 209 

166. Curved Scissors, 209 

167. Retractor, 209 

168. Blunt Hook, 210 

169. Needle-holder, 210 

170. Needles, 210 

171. Needle with Loop for Suture, 210 

172. Slight Fissure of Cervix, 212 

173. Extensive Laceration of Cervix (Munde), 212 

174. Bilateral Laceration of Cervix (Munde), 213 

175. Slight Stellate Laceration of Cervix (Munde), 213 

176. Extensive Stellate Laceration of Cervix (Munde) , 213 

177. Laceration of Cervix with Hypertrophy and Eversion of Cervical 

Mucous Membrane (Munde) , 213 

178. Blunt and Sharp Curets, 215 

179. Edges of Laceration Turned by Tenaculum Hooked into Each Lip, — 216 

180. Denudation of Lacerated Cervix, 217 

181. Surfaces Denuded Ready for Union, 217 

182. Sutures Introduced, 217 

183. Sutures Tied, : 217 

184. Double Flap Amputation of the Cervix (Auvard), 218 

185. Sutures Introduced (Auvard), 218 

186. Wound Closed, _--_ 218 

187. Schroder's Single Flap Operation, 219 

188. Schroder's Operation Completed, 220 

189. Scheme Showing Various Fistulae, 222 

190. Large Vesicovaginal Fistula with Prolapse of the Anterior Vesical 

Wall through the Opening, 223 

191. Denudation of the Edges of the Fistula, 224 

192. Sutures Introduced, 225 

193. Wound Closed, 226 

194. Method of Suturing to Decrease the Tension upon the Sutures, _ 227 

195. Showing Continuation of Suturing to Close Fistula with Incisions to 

Decrease Tension with Suture Introduced on Left Side to Close 

the Secondary Opening, 228 

196. Wound Closed. 228 

197. Fistula Preparatory to Splitting into Vesical and Vaginal Flaps, 229 

198. Demonstration of Flap-splitting, 229 

199. Suture Introduced into Vesical Flap; 230 

200. Suture Tied in Vesical Flap Introduced in Vagina, 230 

201. Wound Closed, 230 

202. Sutures Introduced to Close Vesical Surface, as Suggested by Wal- 

cher, 231 



LIST OF ILLUSTRATIONS. XXVll 

FIG. PAGE. 

203. Flap-formation as Suggested by Ferguson, 232 

204. Flap Turned in and Vesical Opening Closed, , 233 

205. Introduction of Vaginal Sutures, 234 

206. Section Showing Projection upon Vesical Surface, 235 

207. Self-retaining Catheter, 235 

208. Vesico-uterine Fistula, 235 

209. Colpocleisis, 236 

210. Closure of Fistula after Its Exposure by Incision through Anterior 

Vaginal Fornix, 237 

211. Fistula Closed into Vagina. Uterine Opening Remains, Which Will 

Close of Itself , 238 

212. Section Showing Suture for Hysterocleisis, 238 

213. Closure of Fistula within Cervical Canal after Splitting Cervix, 239 

214. Hysterocleisis, 240 

215. Anterior Lip of Cervix Utilized to Close the Fistula 241 

216. Vesico-utero vaginal Fistula in which the Posterior Lip of the Uterus 

is Utilized to Close the Opening, 241 

217. Vesical Wall Loosened and Sutured. Vaginal Wall Suttired in Oppo- 

site Direction, 242 

218. Operation for Uretero vaginal Fistula, 243 

219. Vaginal Implantation of the Ureter into the Bladder, 244 

220. Abdominal Transplantation of Ureter for Ureterovaginal Fistula, 245 

221. Ureteral Anastomosis, 246 

222. Sagittal Incision for Rectovaginal Fistula, 247 

223. Lauenstein Suture in Rectovaginal Fistula through Rectal Wall, 247 

224. Rectal Wall Closed by Transverse Line of Sutures; Vaginal by Ver- 

tical Line of Sutures, 248 

225. Rectovaginal Fistula Closed in Operation of Perineorrhaphy, 249 

226. Rupture of Perineum into Rectovaginal Septum, 250 

227. Cystocele, 251 

228. Rectocele, 252 

229. Right and Left Curved Scissors, . 253 

230. Incomplete Rupture of the Perineum, 254 

231. Simon-Hegar Method of Denudation, 254 

232. Sutures Introduced to Close the Wound, 255 

233. Garrigues' Modification of the Hegar Operation, 256 

234. Upper Part of the Wound Closed; Last Sutures Introduced 257 

235. Wound Completely Closed, 257 

236. Lauenstein Suture, 258 

237. Rectum and Vagina Closed with Lauenstein Suture 258 

238. Hildebrandt's Method of Suturing, 259 

239. Hildebrandt Suture Closed 260 

240. Heppner's Figure-of-8 Suture, 261 

241. Martin Suture to Close the Rectal Opening, 262 

242. Martin Suture Continued, 262 

243. Denudation for Freund's Operation, 263 

244. Sutures Inserted in Rectal Wall and Lateral Vaginal Angles. 264 

245. Vaginal Angles and Rectal Wall Closed. Suture in Place for Peri- 

neum, 264 

246. Denudation Completely Closed, 264 

247. Emmet's Operation. Surface Denuded and Lateral Sutures in Place, 265 

248. Emmet's Operation. Lateral Angles Closed and Perineal Suture 

Introduced, 266 

249. Emmet's Operation Completed 267 

250. Emmet's Operation for Complete Laceration, 267 

251. Suture to Unite the Ends of the Sphincter, 267 

252. Outerbridge's Suture, 268 

253. Cleveland's Suture, 269 

254. Denudation for Martin's Operation, 269 

255. Dudley's Operation with Interrupted Sutures, 270 

256. Dudley's Operation Completed, 270 

257. Vaginal Surfaces United; Perineal Sutures in Place, 271 



XXVlll LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

258. Bischoff's Operation, 271 

259. Splitting Vaginal Wall Preparatory for Suture (Andrews) , 272 

260. Introduction of Suture in Retracted Flap (Andrews) , 273 

261. Suture Tied; the Remaining Surface to be Closed by Transverse 

Sutures (Andrews) 274 

262. Outline of Flap to be Turned down to Form Raw Surface for Union. 

Flap thus Formed to Protect from Fecal Infection (Ristine) , 275 

263. Flap Turned down. Sphincter Closed and Sutures Introduced 

(Ristine), 276 

264. Incision for Tait's Operation for Incomplete Laceration, 277 

265. Line of Incision for Tait's Operation for Complete Laceration, 278 

266. Appearance of Surface after Formation of Flaps, 278 

267. Outline for Simpson's Operation, 279 

268. Sutures Introduced in Simpson's Operation, 280 

269. Denudation for Fritsch's Operation, 281 

270. Catgut Sutures for Union of the Rectal Wall, 282 

271. Incision for Duke's Operation, 282 

272. Incision Separated in Vertical Direction, 283 

273. Incision United by Transverse Sutures, 283 

274. Follicular Vulvitis (Thomas and Mvinde) , 290 

275. Cyst of Bartholin's Gland (^wi;af(i), 296 

276. Kraurosis Vulv«, 300 

277. Urethra Laid Open with Probes, Distending Skene's Glands. Poste- 

rior Wall Divided (Byford, ajter Skene) , 313 

278. Reflex Catheter, 317 

279. Double-current Catheter, 327 

280. Simple Papillary Erosion of the Cervix, 332 

281. Simple Papillary Erosion with Enlarged Follicles, 332 

282. Chronic Endocervicitis, 333 

283. Lines of Incision for Contracted or Pinhole Os (Thomas and Munde) , __ 337 

284. Union of Vaginal and Cervical Mucous Membranes, 337 

285. Interstitial Endometritis, 348 

286. Hypertrophic Glandular Endometritis, Showing Increase in Size and 

Numbers of Glands, 349 

287. Hypertrophic Glandular Endometritis. Vertical Section through 

Glands, 350 

288. Polypoid Masses Associated with Chronic Endometritis, 351 

289. Membranous Dysmenorrhea, 352 

290. Uterus Dilated with Graduated Bougies, 363 

291. Uterine Cavity Packed with Gauze after Dilatation, 364 

292. Acute Salpingitis, 366 

293. Chronic Salpingitis Showing Agglutination of Folds, 367 

294. Extensive Pus Collections with General Adhesions, 368 

295. Pyosalpinx, 369 

296. Section from Wall of Pus Tube, 370 

297. Single Fold from Wall of Pus Tube Enlarged, 370 

298. Distended Pus Tubes Removed from Young Girl, 371 

299. Convoluted Fallopian Tube from Perisalpingitis, 372 

300. Incomplete Inflammatory Closure of the Fallopian Tube. Portions 

of Fimbriae Unretracted, 372 

301. Double Tubo-ovarian Collection, 373 

302. Hydrosalpinx, 374 

303. Double Pyosalpinx Showing Adhesions to the Rectum, to the Uterus, 

and on the Right to the Appendix, 375 

304. Peri-oophoritis. Tube and Ovary Encysted, 377 

305. Resection of Tube, 382 

306. Operation of Resection of Tube Completed, 382 

307. Exudation in Broad Ligament from Pelvic Cellulitis, 388 

308. Exudation of Cellulitis over Rectum, 389 

309. Induration from Peritonitis, 403 

310. Induration from Pelvic Cellulitis. 404 

311. Intestines Held Back by Gauze. Patient in Trendelenburg Posture. __ 408 



LIST OF ILLUSTRATIONS. XXIX 

FIG. PAGE. 

312. Three-pronged Vulsellum, 410 

313. Vaginal Incision for Ptis Collection in the Broad Ligament. 411 

314. Incision through Vagina with Thermocautery in Vaginal Excision of 

the Uterus, 412 

315. Clamp Forceps for Securing the Broad Ligament 413 

316. Deschamps Needle Ligature Carrier, 413 

317. Drawing down the Fundus {Landau) , 414 

318. Application of the Clamp Forceps to the Lower Portion of the Broad 

Ligament {Landau) , 415 

319. Ligation of the Broad Ligament in Vaginal Hysterectomy, 416 

320. Upper Portion of the Broad Ligament Secured by Clamp Forceps 

{Landau) , 417 

321. The Introduction of Gauze after the Removal of the Uterus, 418 

322. Closure of the Vaginal Wound by Sutures, 419 

323. Landau's Method of Delivering the Uterus after Its Complete Median 

Section, 420 

324. Uterus Displaced by Distended Bladder, 421 

325. Uterus Displaced by Impacted Rectum, 422 

326. Scheme of Dislocated Uteri {Dudley), 423 

327. Uterus pushed up by Tumor in Douglas' Pouch, 424 

328. Uterovaginal Prolapse, : 425 

329. Vagino-uterine Prolapsus, 426 

330. Vagino-uterine Prolapsus with Hypertrophic Elongation of the Cervix 

(.4 iivard) , 427 

331. Uterus Detached Showing Hypertrophic Elongation of the Cervix 

{Auvard), 428 

332. Vulvar Appearance of Vagino-uterine Prolapsus 429 

^^T,. Pseudoprolapsus. Cervix within the Vagina, 430 

334. Pseudoprolapsus. Cervix Protruding from the Vulva, 431 

335. Anterior and Posterior Colpocele, 432 

336. Cystocele, 433 

337. Prolapsus with Both Rectocele and Cystocele, 434 

338. Irreducible Prolapsus. The Tumor Contained Uterus and a Large 

Pyosalpinx. Ulceration of the Cervix, 435 

339. Prolapsus without Protrusion of the Vaginal Walls, 436 

340. Determination of the Position of the Uterus by Bimanual Palpation, __ 437 

341. Recognition of the Uterus with Thumb and Finger of One Hand, 438 

342. Diagnosis of Position of the Uterine Body b}" Rectal Touch, 439 

343. Hypertropiiic Elongation of the Cervix. Anterior Vagina Everted, 

while Posterior Retains Its Normal Position {Auvard) , 440 

344. Enterocele through the Posterior Vaginal Fornix, 441 

345. Vagino-uterine Prolapse Complicated by Proliferating Epithelioma, __ 442 

346. Ring Pessary, 444 

347 . Disc Pessar}^, 444 

348. Smith-Hodge Pessary, 444 

349. Munde Pessary 444 

350. Hoffman Soft-rubber Pessary, 445 

351. Zwank Pessary, 445 

352. Gehrung Pessary, 445 

353. Hewitt Cradle Pessary, 445 

354. Anterior Colporrhaphy. Anterior Vaginal Wall Removed, 447 

355. Wound Closed 448 

356. Stoltz Purse-string Suture {Pozzi), 449 

357. First Stage of Dudley's Bilateral Denudation of the Vaginal Walls 

for Prolapsus {Dudley), 451 

3 58. Dudley's Operation, Showing Denudation upon One Side of the 

Vagina {Dudley) 452 

359. Urethrocele, _' 453 

360. Anteversion of the Uterus, 455 

361. Sims' Operation for Anteversion {Auvard) , 457 

362. Abdominal Belt, 457 

363. Retroversion, 458 



XXX LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

364. Slight Degree of Anteflexion, 460 

365. Acute Anteflexion, 461 

366. Thomas Anteflexion Pessary, 464 

367. Stem Pessary, 464 

368. Section Showing Thinning of Cervical Walls at the Angle of Flexion, __ 464 

369. Anteflexion Associated with Contraction of Uterosacral Ligaments, 465 

370. Dudley's Operation for Anteflexion, by Incising and Suturing the 

Posterior Lip {Dudley), 466 

371. Completion of Dudley's Operation, by Transverse Denudation and 

Suturing of the Anterior Lip, 467 

372. Nourse's Operation by Splitting the Cervix and Resuturing the In- 

cisions, 468 

373. Operation Completed, 468 

374. Retroflexion of Slight Degree, 469 

375. Retroflexion of Extreme Degree, 470 

376. Retroflexion Following Version, 471 

377. Retroflexion Produced by Fibroma of Anterior Uterine Wall 472 

378. Retroflexion the Sequel of Inflammatory Adhesions {Thomas and 

Munde) , 472 

379. Retroflexion Simulated by Posteri or Uterine Myoma , 473 

380. Retroflexion Simulated by Small Ovarian Cyst in Posterior Culdesac,. 473 

381. Anteflexion and Retroflexion Simulated by Pelvic Exudation, 474 

382. The Retroverted Uterus Replaced; Patient in Dorsal Position, 475 

383. Schultze's Method of Replacing an Adherent Retroverted Uterus, 476 

384. Second Step in Replacing Uterus by Schultze's Operation, 477 

385. Schultze's Pessary, 478 

386. Proper Position of the Pessary, 479 

387. Faulty Position of the Pessary, 480 

388. Schultze's Sledge Pessary, 481 

389. Alexander's Operation: Round Ligament Exposed {Edebohls) , 482 

390. Round Ligament Being Drawn out {Edebohls) , 483 

391. Round Ligament Sutured {Edebohls), 484 

392. Continuous Catgut Suture Uniting Internal Oblique Muscle to Pou- 

part's Ligament {Edebohls), 485 

393. Return Layer of Suture Bringing External Oblique Muscle in Apposi- 

tion {Edebohls), 486 

394. Wylie's Operation for Shortening the Round Ligaments within the 

Abdomen {Am. Sys. Gyn.), 487 

395. Mann's Operation for Intra-abdominal Shortening of Round Liga- 

ments {Am. Sys. Gyn.) , 488 

396. Dudley's Operation of Desmopycnosis {Am.J.Obs.) 488 

397. Dudley's Operation Completed {Am. J. Obs.), 489 

398. Gilliam-Ferguson Operation. Round Ligament Seized through 

Stab Wound, 489 

399. Round Ligament Drawn through the Abdominal Wall, 490 

400. Section Showing Position of the Uterus with Completion of the 

Operation, 491 

401. Sutures Introduced for Ventro-suspension, 492 

402. Partial Inversion of the Uterus, Showing Three Degrees {Auvard) 501 

403. Intra vaginal Inversion ; Three Degrees {A uvard) , 501 

404. Extra vaginal Inversion; Three Degrees {Auvard) , 502 

405. Nonpuerperal Inversion. Fibroid Tumor Attached to the Fundus 

Uteri, 503 

406. Palpation of an Inversion of the First Degree {Auvard), 504 

407. Palpation of an Inversion of the Second Degree {Auvard), 505 

408. Appearance of an Inversion of the Third Degree, 506 

409. a. Inversion of the Uterus, b. Fibroid Polypus, c. Fibroid Poly- 

pus, with Stenosis of the Cervical Canal, _-_ 507 

410. a. Submucous Fibroma, b. Partial Inversion, c. Partial Division 

of the Uterus. 508 

411. Prolapsus of the Uterus without Inversion, 508 

412. Inversion of the Uterus, Extravaginal 509 



LIST OF ILLUSTRATIONS. XXXI 

FIG. . PAGE. 

413. Central Taxis (Ativard) , 510 

414. Lateral Taxis (Auvard), 511 

415. Peripheral Taxis (Auvard) , 512 

416. The Use of the Air Pessary to Reduce an Inversion (Auvard) , 513 

417. Reduction of Inversion with AVhite's Apparatus (Thomas) 513 

418. Intraperitoneal Dilatation of the Uterus (Thomas) , 514 

419. Incision of the Posterior Uterine Wall Preliminary to Reduction of an 

Inversion, 515 

420. Prolapsus of Ovary and Tube behind Uterus, 516 

421. Intraperitoneal Hemorrhage (Auvard), 527 

422. Extraperitoneal Hematoma (Courty), 530 

423. Tubal Pregnancy (Sutton), 535 

424. Tubo-ovarian Pregnancy, 536 

425. Tubo-uterine or Interstitial Pregnancy, 536 

426. Tubal Abortion, 537 

427. Complete Rupture of a Tubal Sac 543 

428. Incomplete Rupture of Gestation Sac, 544 

429. Ectopic Gestation Sac Ruptured Showing Fetus, 551 

430. Large Ectopic Gestation Sac 555 

431. Anterior Labial or Inguinal Hernia 572 

432. Posterior Labial Hernia, ^y;^ 

433. Urethral Caruncle, 575 

434. Prolapsus Urethras, 576 

435. Varicose Veins of the Vulva (Dr. W.Kriisen) 577 

436. Vulvar Vegetations, 579 

437. Elephantiasis of the Vulva, 581 

438. Fibroid of Labium, 582 

439. Cancer of the Vulva, 583 

440. Appearance of the Vulva after an Operation for Cancer of the Vulva, __ 584 

441. Cysts of the Vagina, 586 

442. Myoma of the Anterior Vaginal Wall (Dr. J. C. Da Costa) 588 

443. Primary Cancer of the Vagina, 589 

444. Microscopic Section ; Myoma Uteri (Co/?/^;*) , 601 

445. Liomyoma of the Uterus (Coplin), 602 

446. Submucous Myoma (Polypoid) 603 

447. Sessile Submucous Myoma, 604 

448. Submucous Myoma Occupying Uterine Cavity, 605 

449. Submucous M^^oma Extruded into the Vagina, 606 

450. Voluminous Myomata Occupying Anterior and Posterior Walls 

(Auvard) , 607 

451. Circumscribed Interstitial Myomata (Auvard) 608 

452. Local Interstitial Myomata (Auvard), 609 

453. Uterus Opened, Showing Multiple Interstitial Myomata, 610 

454. Subserous Myomata, 611 

455. Pedunculated Myoma of the Cervix, 612 

456. Sessile Myoma of the Cervix, 613 

457. Bicornate Uterus. Both Cornua Containing M^^omata, 616 

458. Intraligamentary M3^oma, 619 

459. Fibroc^^stic Tumor of the Uterus (Auvard), 626 

460. Myoma of the Body and Cancer of the Cervix 628 

461. Myoma Uteri Complicated by Pyosalpinx, 630 

462. A Myoma Which, from the Associated Ascites, Had Been Mistaken 

for Pregnancy, 631 

463. Tumor Shown after Removal, 632 

464. Myoma Complicated by Pregnancy, 62)2, 

465. Incision of Cervix to Expose Intra-uterine M\^oma, 647 

466. Cervix and Capsule Incised, the Latter Pushed Back, 648 

467. Removal of Myoma by Torsion of Its Pedicle 649 

468. Incision of Pedicle of Myoma, 650 

469. Enucleation of Tumor through the Vagina, 651 

470. Interstitial Tumor Exposed by Vertical Incision of the Anterior Lip, __ 652 

47 1 . Myoma of Anterior Wall Exposed by Transverse and Vertical Incision, . 653 



XXXll LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

472. Myoma of Posterior Wall Exposed by Retro-uterine Incision, 654 

473. Removal of Myoma by Morcellement, 655 

474. Abdominal Myomectomy {Dudley), 661 

475. Abdominal Enucleation of Myomata and Method of Closing the 

Uterine Wound (Dudley) , 662 

476. Supravaginal Removal of Myomatous Uterus (Kelly) , 666 

477. Cervix Cut Across Preliminary to the Complete Ligation of One 

Ligament (Kelly, modified), 667 

478. Stump Covered with Peritoneum, 668 

479. Panhysterectomy. Do5Aen's Method, 671 

480. Cervix Separated from the Vagina, and Being Pulled away from the 

Bladder and Ureters, 672 

481. Mucous Polypi, 684 

482. Squamous-cell Epithelioma of the Uterus, 687 

483. Adenocarcinoma of Body of the Uterus, 688 

484. Cauliflower Growth Involving the Vaginal Part (Winter) , 692 

485. Cancerous Ulceration of Intracervical Canal (Auvard) , 694 

486. Cervical Wall Infiltrated while the Vaginal Portion is Largely De- 

stroyed (Veii), 695 

487. Circumscribed Cancer of Body of Uterus (Auvard) 696 

488. Diffuse Cancer of Uterine Body, 697 

489. Entire Cavity Covered with Nodular Growths, 698 

490. Communication between Bladder, Vagina, and Rectum (Auvard), 701 

491. Cervical Canal Destroyed by Progress of Disease, 703 

492 . Uterus Removed from an Unmarried Woman Twenty-two Years of Age, 710 

493. Formation of Flap to Cover Diseased Surface Preliminary to Opera- 

tion, 728 

494. Ligation of the Anterior Trunk of the Internal Iliac, 741 

495. Skin Incision for Sacral Resection, 745 

496. Sacrum Resected; Rectum Exposed, 746 

497. Rectum Pushed Aside ; Uterus Exposed, 747 

498. Patient from Whom Uterus, Ovaries, Posterior Wall of Vagina, 

Perineum, and Five Inches of the Rectum Have Been Removed, __ 750 

499. Chorio-epithelioma Malignum (Noble and Tracy) , 770 

500. Endothelioma of the Uterus, 772 

501. Sarcoma of the Body of the Uterus, 774 

502. Fibroma Undergoing Sarcomatous Change (Auvard), 784 

503. Papilloma of the Fallopian Tube (Doleris), 791 

504. Broad Ligament Cyst (Sutton) , 793 

505. Broad Ligament Cyst, with Torsion of Its Pedicle, 794 

506. Large Ovarian Tumor, 797 

507. Small Residual Cysts (Dudley), 798 

508. Cyst of the Corpus Luteum, 799 

509. Tubo-ovarian Cysts. 800 

510. Large Ovarian Cyst. Patient Upright, 801 

511. Ovarian Cyst. Patient Recumbent, - 802 

512. Pedicle of an Ovarian Cyst (Doran), 802 

513. Intraligamentary Ovarian Cyst, 803 

514. Cyst Embedded in the Pelvis, 804 

515. Adenocystoma of Ovary, Showing Papillary Formation, 805 

516. Areolar Ovarian Cyst, : 806 

517. Unilocular Ovarian Cyst (Winter), 807 

518. Multilocular Cyst (Doran), 808 

519. Small Papillary Ovarian Cyst, 809 

520. Papillary Tufts upon Inner Wall of Cyst (Doran), 809 

521. Surfaces"^ of Ovaries Infected with Papillary Vegetations (Doran) , 810 

522. Dermoid Ovarian Cyst, 811 

523. Fibromyoma of Ovary (Veit) , 813 

524. Sarcoma of the Ovary (Veit) , 813 

525. Torsion of the Pedicle, 818 

526. Dermoid Which Had Lost Its Original Relations and Was Nourished 

by Adhesions from the Omentum, 820 



LIST OF ILLUSTRATIONS. XXXlll 

FIG. PAGE. 

527. An Ovarian Cyst beneath a Pregnant Uterus, 823 

528. Desmoid Tumor of Abdominal Wall, 825 

529. Relative Zones of Dulness and Resonance in Ascites, 827 

530. Relative Zones of Dulness and Resonance in Ovarian Cysts, 828 

531. Hegar's Method of Determining Relation of Tumor to the Uterus 

(Winter), 830 

532. Cyst Forceps, 842 

533. Wall Incised; Cyst Exposed, 843 

534. Cyst Punctured and Being Withdrawn, 844 

535. Withdrawal of Sac, Showing Adhesions, 845 

536. Ligatures Introduced through Broad Pedicle, 846 

537. Interlacing of Sutures to Prevent Splitting of Pedicle, 846 

538. Sutures Interlaced and Tied 847 

539. Splitting of Pedicle when Sutures are Tied without Interlacing, 848 



i 



A 

Text-book of Gynecology 



INTRODUCTION. 

1. Definition and Antiquity. — Gynecology comprises the study 
of the diseases peculiar to Avomen. While it is not to be denied 
that some of the diseased conditions of the female genital tract 
were known to the ancients, as demonstrated by the description 
of the sound and of various forms of specula, as well as the direc- 
tions for the treatment of special conditions, it is certainly true 
that the most marked development of the science has occurred 
during the nineteenth century. 

2. Theories. — The study of its progress is not Avithout interest 
and profit, and in its development Ave witness the pendulum 
SAA^ng from one extreme to the other. The origin of disease is 
based upon local inflammation by one ; by another it is ascribed 
to constitutional conditions of Avhich the local condition is only 
an expression. The cerA^ix has been considered the offending 
portion of the tract, and its inflammation the cause of CA'cry 
trouble. The ovaries have been accused of dominating the other 
organs, and producing in them secondary or reflex phenomena. 
Displacements of the uterus, particularly the flexions, have been, 
and still are, asserted to be the main source of the disorders 
of the pelvis. To the tubes has been assigned the function of 
menstruation, and consequently to pathologic lesions of these 
organs are attributed the majority of abnormal conditions of 
the genital tract. 

3. Foundation. — When we come to analyze the different 
theories AA^hich have been presented, we find the truth is contained 
not in one, but in a proper combination of all. The influence 
of the organs upon each other, due to the arrangement of Avascular 
and nerve supply, is significant, and a proper appreciation of the 
science is attained only by a very careful study and analysis of 
all the phenomena presented. 

4. Purpose. — It should not be considered the true province 
of gynecology, on the one hand, to ascertain that the patient has 

2 17 



18 GYNECOLOGY. 

a uterus which must be subjected to the routine use of speculum, 
sound, and appHcator ; nor, on the other, that the demonstration 
of the existence of the ovaries and tubes justifies the conclusion 
that every symptom of distress or discomfort of which the pa- 
tient complains must result from a pathologic lesion in them 
which will of necessity justify their sacrifice. The gynecologist 
must be one who will be patient in eliciting the subjective symp- 
toms and proficient in determining physical signs, and who will 
exercise correct judgment in comparing and analyzing the knowl- 
edge thus secured; one who has such integrity that the patient 
may feel assured she will not be treated for diseased conditions 
which are not present. 

He must be so conservative that he will sacrifice no organ 
whose physiologic integrity is capable of being restored ; so bold 
and courageous that his patient shall not forfeit her opportunity 
for life or restored health through his failure to assume the respon- 
sibility of any operative procedure necessary to secure the object. 

5. Difficulties in Study. — The importance of correct diagnosis 
can not be too strongly affirmed, yet probably in no department 
of medicine are interposed greater barriers to its accomplish- 
ment. In the study of the diseases of women much must depend 
upon proficiency of touch, which can be acquired only by exten- 
sive practice. The delicacy and proficiency of this sense varies 
so greatly in different individuals that it is difficult to convey an 
adequate idea of the relative hardness or softness of the struc- 
tures under observation. 

The ovaries and tubes, in which important lesions may occur, 
are in some patients quite inaccessible to ordinary methods of 
examination. Pathologic lesions must often, then, be the sub- 
ject of inference or speculation rather than capable of absolute 
demonstration. To add to the difficulty of study of symptoms, 
the mere thought of subjecting herself to examination is repug- 
nant to the modesty of every woman, and the disease occurs in 
organs so sensitive that they can not be subjected to manipula- 
tion by a number of persons in succession. The patients who 
are willing to be brought before a class of students and subjected 
to repeated examination are exceedingly few, consequently many 
practitioners must enter upon their vocation with but little or no 
practical knowledge of the subject. 

6. Observation. — The cultivation of habits of close observa- 
tion is of the utmost importance. The observing physician will 
often be able to determine with considerable accuracy the cir- 
cumstances, condition, and diseased state of the patient from her 
conduct, manner, and general appearance. Thus, a woman with 
an abdominal enlargement who enters a physician's office with a 
face presenting the rosy hue of health, and appears well nour- 



INTRODUCTION. 19 

ished, would be suspected of suffering from a physiologic rather 
than a diseased condition, and would be pronounced pregnant; 
while such an enlargement associated with a pale countenance, 
an emaciated face, thin cheeks, and sunken eyes would be re- 
garded as indicating an ovarian growth. This special association 
of the features is known as fades ovariana, and is of value in 
forming the diagnosis. The conduct and deportment of the 
patient will frequently announce whether she is married or 
single ; her manner of walking or sitting, the existence of a pelvic 
inflammation. 

7. Exercise of Judgment. — Errors in diagnosis are most fre- 
quently caused by hasty conclusions founded upon insufficient 
investigation. The recognition of the existence of some lesion 
is at once accepted as an explanation for all the distressing 
symptoms. To be accurate, the judgment should not be given 
until a careful and thorough examination of every organ cap- 
able of producing such symptoms has been made. 

8. Value of Notes. — The young physician should accustom 
himself to taking notes of his office cases ; he thus forms the habit 
of more careful and systematic investigation of every patient, 
accumulates data from w^hich he is enabled to formulate more 
definitely judicious plans of treatment, and, probably most im- 
portant of all, has the means of refreshing his mind from time to 
time as to the condition of any particular patient. 

9. History. — Such a schedule should comprise the name, 
residence, age, condition of patient, married or single, family history, 
personal history (as previous sickness, duration of present illness, 
supposed cause, progress and symptoms). 

Menses: first appearance, regularity, duration, what changes 
have since occurred; present habit, date of last menstruation. 

Pain, whether it precedes, accompanies, or follows the periods, 
its character, severity, and where experienced. 

Leukorrhea: amount of discharge, duration, continuance, 
color, consistence, and effect upon the parts with which it comes 
in contact. 

Number of children or miscarriages : character of labor and 
convalescence and the influence upon subsequent health. 

Coition: painful, sensation, frequency, methods employed to 
avoid conception. 

Interrogation of other organs: regularity of alvine dejections, 
frequency of micturition, digestion; pain in head, in lumbar 
region, in groins, down the limbs, etc. 

The inquiry need not, possibly should not, in all cases pursue 
the order here laid down. In some instances it will be better to 
permit the patient to tell her own story ; in others it will be neces- 
sary to guide her course by an occasional judicious question, or 



20 GYNECOLOGY. 

to assume the position of questioner, and patiently endeavor to 
secure a complete history. While the appearance and the char- 
acter of the symptoms may indicate a certain interpretation, the 
physician should reserve his judgment as to the condition until 
the testimony of subjective and objective symptoms has been 
completely secured, and then arrive at the diagnosis after their 
careful analysis. 

DIAGNOSIS. 

10. Subjective Symptoms.— The subjective symptoms are 
those which are elicited from the patient or her attendants. As 
already asserted, the difficulty experienced in determining the 
physical signs frequently made these symptoms of great value. 
Every such symptom, however, must be carefully weighed, as 
both patient and attendants may exaggerate the character and 
severity of symptoms or err in observation and in interpretation. 

11. Causes of Error. — Lisfranc * writes: "By their almost 
latent state, their great variety of symptoms (often very transi- 
tory), their sympathetic effects on all parts of the economy, and 
their immense influence on the nervous system, uterine diseases 
are peculiarly apt to lead medical practitioners into errors of 
diagnosis." 

The reason for these errors is the difficulty in understanding 
their cause. The uterine symptoms are not always the most 
prominent, are slowly developed, and do not always attract the 
attention of the patient. Not infrequently is the physician con- 
sulted for disorder of the stomach, of the heart, or of the liver; 
for vomiting, nausea, want of appetite, or diarrhea ; for neuralgia 
or hysteria ; for a train of evils having their origin in poverty of 
the blood, as chlorosis, anemia, emaciation, and exhaustion — all 
of which may be symptomatic manifestations of an obscure 
uterine malady. 

12. Method of Procedure. — The examination should proceed 
from general to local symptoms in such a manner as to bring the 
patient to the conviction, at which the physician has already 
arrived, that the only logical outcome is a ph3^sical examination. 

13. General Symptoms.— There are many cases of disease in 
which the general or constitutional symptoms are very predomi- 
nant, so much so, indeed, as to wholly obscure the diagnosis and 
lead both patient and physician to believe that organs other than 
those of the pelvis are directly at fault. The symptoms of which 
complaint will be most frequently made are gastric, such as 
gastralgia, nausea, vomiting, perverted appetite, anorexia, and 

* " Clinique Chirurgicale de la Pitie," vol. 11, p. 182, Paris, 1842. 



DIAGNOSIS. 21 

regurgitation associated Avith a clean tongue. Nausea and 
obstinate vomiting are very likely to be associated with ovarian 
disease. Nervous anesthesia affects portions of the lower ex- 
tremities, as over the front of the thighs. It is especially prone 
to extend to and involve the clitoris, genitals, and vagina, when 
all sexual desire and pleasurable sensation during coition become 
lost. 

14. Visceral Neuralgias. — The bladder and rectum are not 
alone the seat of pain, but remote organs are also aft'ected, such 
as the liver, stomach, intestinal canal, and heart. Patients not 
infrequently suffer from symptoms which cause them to believe 
themselves the victims of a serious disorder of the heart, which 
entirely disappear upon proper treatment directed to a pelvic 
lesion. 

15. Neuralgia in the lumbar and dorsal regions, — intercostal 
neuralgia of the left side, — leading the patient to fear the exist- 
ence of organic heart disease, is common. The trifacial nerve 
may be involved, producing the sensation of a nail being driven 
into the head. Sympathetic pains are frequently noticed in the 
heart, with a sensation of swelling, especially marked during 
menstruation. I have often observed intense pain felt in the 
breast associated with a chronic inflammation of the correspond- 
ing ovary. The pain is usually ameliorated or absent during 
menstruation, but aggravated during the menstrual intervals. 

16. Motor and sensory paralysis is not an infrequent concomi- 
tant of uterine disorder. It is often difficult to determine its 
cause. It is usually of a hysteric character, and numerous cases 
have been recorded where the replacement of a displaced uterus 
has resulted in the rapid cure of a case of complete paraplegia. 

17. Disorders of Nutrition. — These may be the result of the 
gastric phenomena resulting in impoverished conditions of nutri- 
tion, such as anemia, chlorosis, and general debility. 

18. Chlorosis is found in poorly nourished girls, who suffer 
from it at puberty, or in women during pregnancy, and is fre- 
quently developed by, rather than originates, the pelvic disorder. 

19. Anemia is most frequently found in older women who 
are suffering from some serious disease, as cancer, fibroid tumors, 
or other growths which have caused repeated and profuse hemor- 
rhages ; consequently it is more a symptom than a morbid affec- 
tion, and results from the presence of disease. When repeated 
hemorrhages have led to impoverishment of the blood, and have 
removed needful materials for repair, or when the patient has 
been weakened by suppuration and insufficient assimilation, there 
is loss of color in the skin, transparency of the tissues, local 
edema, frequent weak pulse, and general debility. These dis- 
eases of nutrition are accompanied not only by general debility, 



22 GYNECOLOGY. 

but also by progressive emaciation, until the disorder producing 
them has been properly treated. Under the influence of the dis- 
eased condition the patient becomes prematurely aged. The 
head is stooped, the limbs are bent, the features are drawn, and 
she presents a look of suffering; the flesh is soft and flabby; the 
countenance is expressionless, the complexion pale and faded, 
especially when leukorrhea has been long continued and profuse. 
The paleness is different from that of ordinary anemia ; it causes 
the characteristic appearance that has been recognized under the 
name of fades uterina (Courty ) . Emaciation may not always be 
present; on the contrary, the patient may sometimes be corpu- 
lent, particularly when amenorrhea, rather than leukorrhea or 
hemorrhage, occurs. The obesity is sometimes so great as to lead 
the patient to believe herself pregnant, and not infrequently, 
while suffering severely, she is congratulated by her acquaint- 
ances upon her excellent appearance. 

20. Local Symptoms. — The local symptoms are those sen- 
sations which are experienced in the genital organs or in those 
organs immediately associated with them. The latter are more 
particularly the rectum and bladder. Reflex phenomena from 
the rectum or bladder, or, on the contrary, sympathetic irritation 
of the uterus, when either of the former organs is the seat of dis- 
ease, are very common, and the frequency of their occurrence can 
be appreciated when we remember that the nerve supply to the 
uterus, rectum, and vagina is derived from the cervico-uterine 
ganglia of the hypogastric plexus. 

21. Rectal Reflexes. — It is not unusual to find that during 
menstruation women suffer from diarrhea. The pelvic vascular 
system is so general that engorgement or inflammation of the 
uterus will not fail to produce congestion in the other pelvic 
organs ; and in any marked inflammation of the organ, associated 
with displacement, and particularly in retrodisplacements, the 
hemorrhoidal vessels will be found to be distended ; thus, hemor- 
rhoids in the female very frequently result from the presence of 
retrodisplacements of the uterus, and these should never be 
subjected to operative treatment until the displacement has been 
corrected. In anteversion the cervix will frequently be found to 
project against the anterior wall of the rectum, and can be readily 
distinguished through this viscus. When the cervix is inflamed, 
the impingement of hard fecal matter against the organ not infre- 
quently causes severe pain. In some cases this pain is expe- 
rienced only during menstruation. The most frequent functional 
disorder of the rectum is constipation; partly from neglect, and 
partly from want of nerve irritation, the bowel becomes filled with 
fecal matter, the watery portions are absorbed, and hard, dense, 
scybalous masses form, w^hich are evacuated with difficulty, and 



DIAGNOSIS. 23 

possibly only after repeated enemata. The muscular coat of the 
bowel becomes distended, loses its tone, and results in a form 
of paralysis ; fecal matter undergoes decomposition, is partly re- 
absorbed, and causes the condition which Barnes has denominated 
as copremia, in w^hich the skin is of a sallow^ dirty hue, presenting 
ill-smelling secretions; the patient suffers from dyspepsia, flatu- 
lence, and pyrosis — a condition akin to that known as uremia. 
The violent efforts at evacuation of the bowels lead not only to 
the formation of hemorrhoids, fissure, sometimes fistula, but they 
may, through the increased intra-abdominal pressure, cause dis- 
placement of the uterus and the vagina. When fissures exist, the 
pain during defecation is so great that the patient is likely to per- 
mit the bowels to go unevacuated rather than endure the result- 
ant pain. 

22. Vesical Reflexes. — The relation of the bladder to the 
uterus is still more intimate than that of the rectum, and conse- 
quently this organ is more likely to be affected in inflammatory 
conditions of the uterus. Retention of the urine may be pro- 
duced by pregnancy or by pelvic growths, such as fibroid tumors 
or tumors of the ovaries. It sometimes occurs, also, as a result of 
irritation of the orifice of the vagina, a condition known as 
vaginismus. The pain may be so great as to produce a spasmodic 
contraction of the sphincter of the bladder. The most usual 
functional derangement of the bladder, however, is frequent 
micturition. It may occur as the result of reflex irritation from 
the pelvic organs, or in consequence of pressure from the uterus, 
produced by the presence of a tumor or by a pregnant uterus or a 
displaced organ in which either the fundus rests forward upon the 
bladder or is turned backward, causing the cervix to press against 
the latter. Either of these conditions may lead to functional 
derangement of the bladder, so marked as to cause the patient to 
suspect the existence of disease of that organ, or, as she will more 
probably say, disease of the kidneys. 

23. Genital Symptoms. — The symptoms attributable to the 
genital organs are derangements in the performance of their 
functions. The particular symptoms are disturbances of men- 
struation, such as a decreased, an increased, or an irregular 
menstrual flow, the existence of sterility, the presence of pain 
and excessive discharge ; consequently, in determining the history 
of the patient, if she is married, we endeavor to elicit information 
regarding previous pregnancies and the character of the labors. 
Sterility in a woman who has been married for a number of years 
is an indication of some abnormal condition. It may be due to a 
malformation, to functional disturbances, to actual disease, or 
to efforts to avoid the responsibility of maternity. It should be 
remembered, however, that there are cases of relative sterility. 



24 GYNECOLOGY. 

The most unvarying function of the uterus is that of menstruation, 
consequently some disturbance in the perfomance of this func- 
tion is one of the first indications of the existence of uterine dis- 
order. Amenorrhea is a term used to signify absent or greatly 
decreased menstrual flow; in menorrhagia the flow, though re- 
gular, is increased, and the menstrual period is lengthened. 
Metrorrhagia is a term employed to designate a flow that does 
not correspond with the regular periods. Dysmenorrhea indicates 
the existence of pain occurring at the beginning of, during, or 
immediately following the menses. These conditions will be 
considered more fully later. 

24. Hemorrhage is by no means a constant symptom of 
uterine disease. Its significance varies according to the amount 
of blood lost and the time of life at which it occurs. During the 
earlier periods of menstrual life it is not uncommon for the menses 
to be very profuse, caused by defective development of the 
ovaries or ovarian hyperemia. When hemorrhage occurs in 
women who have borne children, it may be produced by inflam- 
mation of the mucous membrane of the uterus — hence a hemor- 
rhagic endometritis; or in women at a more mature age, it may 
result from villous degeneration of the endometrium (Goodell), a 
condition demanding careful investigation to discover or exclude 
malignant disease. Hemorrhage is very commonly associated 
with fibroid growths of the submucous variety. Uterine polypi, 
whether due to a fibroid growth or to vascular growths upon the 
endometrium, are a very prolific cause near the climacteric. The 
occurrence of hemorrhage subsequent to the menopause should 
always cause the physician to suspect the possibility of malignant 
disease in either the mucous membrane of the cervix or the body 
of the uterus. When hemorrhage occurs during or following 
pregnancy, it is probably due either to a threatened abortion or 
to retention of portions of the fetal envelopes. It should not be 
forgotten, however, that hemorrhage may occur from cystic 
disease of the ovaries, and in some cases in which the pelvic 
organs present no lesion, as from valvular disease of the heart. 
Bright 's disease, and obstruction of the portal circulation of the 
liver. 

25. Pain is a very frequent symptom ; it may be associated 
with the menstrual function, when it is known as dysmenorrhea, 
or may be independent of it. When it occurs during coition, it 
is known as dyspareunia (Barnes). It may be dependent upon, 
first, vaginismus ; second, chronic nervous irritability due to in- 
complete or awkwardly performed first coitus; third, inflam- 
mation; fourth, tumors; and fifth, malformations. 

26. Seats of Pain. — Courty assigns six seats of pain, three 
of which are principal and three accessory. The principal seats 



DIAGNOSIS. 25 

are, first, the iliac regions; second, the loins; and, third, the 
hypogastrium. 

27. The iliac pain is the most frequent ; it is felt in the region 
of the iliac fossa, and extends from it to the hypogastric and 
lumbar regions, particularly toward the pelvic brim and cavity. 
This pain is most often felt upon the left side. It is probably due 
to tension of the broad ligament, and occurs upon the left side 
more frequently on account of the arrangement of the circulation 
through the veins. The left ovarian vein enters the left renal 
at a right angle, and passes behind the sigmoid flexure of the colon 
to reach it. The frequent impaction of this portion of the gut 
with feces would account for the obstructed circulation. 

Courty ascribes pain in this region, however, to the inclination 
of the uterus to the right ; hence any increase in size of the organ 
causes a gradual dragging upon the left broad ligament. 

28. Lumbar pain, generally spoken of as backache, is felt in 
the lower part of the lumbar region, sometimes extending to the 
region of the kidneys, and, in others, and more frequently, down 
over the sacrum. In some cases the abdomen is encircled as 
with a belt of pain. This pain is usually ascribed to traction 
upon the uterosacral ligaments. It is doubtless not infre- 
quently due to retention of secretion within the cavity of the 
uterus, by w^hich that organ is obliged to go into labor in order to 
secure its expulsion. Its presence indicates disease of the cervix ; 
when it is particularly marked in the sacrum, it is the probable 
result of retrodisplacement of the uterus. 

29. Lateral Pain. — Pain felt upon either side of the pelvis, 
recurring or intermittent in character, is frequenth^ due to the 
effort of an inflamed Fallopian tube to expel its retained secretions 
into the uterus. 

30. Hypogastric pain is experienced above the pubes, and, 
more than any other, seems to have its origin in the uterus. It 
is artificially elicited, rather than occurring spontaneously. 
Patients who do not experience it ordinarily, complain as soon as 
pressure is made over the lowxr portion of the abdomen. This 
pain is greatly aggravated in w^alking, so that the patient not in- 
frequently experiences the necessity of support over the hypogas- 
trium by means of a belt or by placing the hands in front, partly 
for support and partly for protection against injury. 

31. The accessory seats of pain Courty ascribes first to the 
anus or perineum; second, to the vagina or cervix; and, third, 
to the cavity of the pelvis. 

32. The anal or perineal pain is usually produced by a retro- 
uterine tumor or retroflexed uterus. Patients with hypertrophy 
of the cervix not infrequently suffer pain in the anus or perineum 
while walking or riding, and often Avhen sitting. 



26 GYNECOLOGY. 

33* Vaginal pain is not so frequent. It is felt in women who 
have inflamed uteri, particularly during an orgasm. 

34. Pelvic pain results usually from inflammation about the 
uterus or from inflammation of the tubes, fixation of the ovaries, 
or when organs have become cystic or the seat of pus collections. 

35. Leukorrhea. — Leukorrhea, or whites, is a term given to 
discharges other than sanguineous that occur from the genital 
tract. To appreciate its significance as an indication of disease, 
we must recognize the character of the normal or physiologic 
secretion. 

36. The secretion from the Fallopian tubes and cavity of the 
uterus is a thin, whitish alkaline fluid; that from the cervical 
glands is also alkaline, but is very viscid, tenacious, and trans- 
parent like white of egg. 

37. The secretion of the vagina and vulva is whitish, made 
up of a serous fluid intermixed with scaly epithelium. The 
vulvar discharge also contains oil-globules from the sebaceous 
glands. The secretion of both vagina and vulva is acid. 

The superfluous discharge from the cervix is coagulated by 
that of the vagina, forming a smeary material at the upper part 
of the vagina, and will be found to coat over the surface of a 
pessary. When the cervical fluid is in excess, it may pass from 
the vagina unchanged and perfectly transparent. 

Another discharge or secretion is that which takes place from 
the vulvovaginal glands during coition or under excitement. 
This is a clear, viscid discharge. In very erotic women this dis- 
charge is ejected upon the approach of a person of the opposite 
sex, and nocturnal discharges occur during erotic dreams. 

It is sometimes diflicult to determine whether a discharge is 
the result of over -stimulation of a physiologic secretion, or is pro- 
duced by a pathologic condition. 

38. Catarrhal Discharge. — A profuse discharge is not an 
infrequent result of exposure to cold. An increased secretion 
from the uterine glands occurs instead of the ordinary nasal flow\ 
A hypersecretion which results from the hyperemia of the preg- 
nant uterus may be considered physiologic. 

In some undeveloped and strumous young women a leukor- 
rhea occurs as a substitute for the menses. In many individuals 
a slight leukorrhea, preceding or following the menses, has no 
abnormal significance. 

39. Origin of Discharge. — The source of origin of an abnormal 
discharge can be determined to some degree by its appearance 
and character. When from the cavity of the uterus, it will be a 
thin, watery fluid, loaded with ciliated columnar epithelium, and 
containing also pus and blood-corpuscles, according to the extent 
of the disease. 



DIAGNOSIS. 27 

40. Discharge Simulating Abscess. — It may be a continuous 
flow, but more frequently it is intermittent, due to obstruction 
from swelling of the mucous membrane of the outlet, which leads 
to dilatation of the cavity and not infrequently of the orifices of 
the tubes. The uterus then empties itself only by occasionally 
going into labor to evacuate its contents. Such a fluid, loaded 
with pus and blood-corpuscles, coming away in gushes, leads the 
patient to believe that an abscess has formed and been evacuated. 
Patients will not infrequently inform you that they have ab- 
scesses form and discharge at short intervals. The conditions 
described, however, may not be the only explanation. An ac- 
cumulation in a tube, the uterine end of which is still patulous, 
may occasionally drain through the uterus. Such a condition 
has been denominated hydrops tuhcB profliiens. 

41. Other sources for purulent discharges are found in the 
rupture of a tubal or peritoneal abscess into the vagina ; the rup- 
ture of a suppurating ovarian tumor, of an extra-uterine preg- 
nancy sac, or of an abscess about the vermiform appendix. 

42. Cervical Discharge. — The discharge from the cervix is 
usually v^ery viscid and tenacious ; it may be clear and transparent, 
or clouded by desquamated epithelium and filled with pus-cells, 
when it is yellowish or greenish-yellow in color, or it may be 
mixed with blood-corpuscles. 

The cervix will usually be dilated and patulous, its membrane 
thickened, abraded, and covered with papillae. 

43- Vaginal Discharge. — A thin, serous discharge flows from 
the vagina in simple inflammation; in more severe attacks it is 
loaded with epithelium, and the vagina is red and inflamed and 
has apparently shed its entire epithelial coat. When due to 
gonorrhea, the discharge is profuse, purulent, ichorous, irritating 
to the external parts, and attended with a burning sensation 
during micturition. 

44. Effect of Age upon the Discharge. — The signiflcance of the 
discharge is also dependent upon the age and physical condition 
of the patient. Prior to puberty it is usually due to irritation of 
the vulva, and is thin and serous, resembling that from eczema. 
After puberty, in the unmarried, it is generally vaginal. In the 
more mature and in married women it is usually uterine. 

As the individual approaches puberty the vulvar discharge 
becomes more oleaginous, from the secretion of the sebaceous 
follicles. Not infrequently, in uncleanly persons, the secretion 
from these glands is so abundant that it decomposes and sets up 
an inflammation similar to the blennorrhea of the male. Prior to 
or following the climacteric a thin, watery flow, of a sweetish, 
sickening, or decayed-flesh-like odor, should be considered a 
strong premonition of cancer of the uterus. 



28 



GYNECOLOGY. 



45. Physical Signs.— The careful study and analysis of the 
subjective phenomena may afford an approximate idea of the 
disorder present, but the diagnosis should not be considered 
completed until the objective symptoms, or physical signs, have 
been investigated. 

46. Senses Employed. — In the study of the physical signs all 
the senses except that of taste are employed : 

The sight is used in inspection of the abdomen and external 
genitalia and in examining the internal organs by the use of the 
speculum. 

The touch is practised in abdominal palpation and percussion, 
in simple vaginal or rectal touch, in conjoined manipulation, and 
in the use of sound or catheter. 

The hearing is employed in percussion and auscultation. 

The smell is exercised in the examination of discharges. 

47. Examination. — The physical signs are recognized through 
an examination, which may be abdominal, pelvic, or a com- 
bination of the two in the bimanual or conjoined manipulation. 

48. Pelvic examination comprises inspection, touch, and in- 
strumental investigation. 

49. Abdominal examination may be classified under inspec- 
tion, palpation, percussion, auscultation, and exploratory punc- 
ture or incision. 

50. Preliminaries. — The verbal examination should have been 
so conducted that upon its completion the patient will be im- 
pressed with the fact that a 
physical examination is the 
only logical conclusion. The 
examination may be made 
upon a sofa or a common 
bed, as would be the custom 
when made at the home of 
the patient; but in office 
practice it will be found more 
convenient to have provided 
a suitable table or chair. The 
choice of table will depend 
upon the custom and conve- 
nience of the operator. One 
made by Codman & Shurtleff , 

of Boston, known as the Chadwick table, is very satisfactory. 
(Fig. I.) In the first examination for the consideration of 
obscure conditions the clothing should be loosened and corsets 
removed, so that the abdominal walls can be completely re- 
laxed. The bladder and rectum should be empty. The latter 
suggestions are very important in order to permit the normal 




Fig. 



-Chadwick Table. 



DIAGNOSIS. 



29 



relations of the uterus and its adnexa to be determined. Fecal 
accumulations have been mistaken for ovarian and tubal en- 
largements or inflammatory exudates. A distended bladder has 
been confounded with an ovarian tumor. The patient should 
be so placed for examination that the pelvis will be exposed to 
a good light. 

51. Positions. — The patient may be placed in one of six 
positions for examination: viz., (i) dorsal; (2) lateral; (3) semi- 
prone (Sims); (4) genupectoral ; (5) Trendelenburg; (6) erect. 
Of the positions named, the 

dorsal and semiprone are 
the most important. 

52. The Dorsal Position. 
— The patient lies upon her 
back, with the limbs flexed 
and feet placed upon sup- 
ports. The feet may be on 
a level with the buttocks or 
placed on supports a toot 
higher. The latter affords 
greater relaxation to the 
abdominal muscles. The 
clothing is lifted over the 
knees. The lower part of 
the body has been previ- 
ously covered with a sheet, 
which is folded about the 
widely separated limbs, and 
permits the inspection of 
the vulva. (Fig. 2.) This 

position permits the ready practice of the bimanual examination, 
and is the most favorable for vaginal and abdominal palpation 
and for the use of the valvular and Edebohls' specula. 

53. The Lateral Position. — The patient lies upon the left 
side, with the limbs at a right angle to the body. This position 
was formerly much used by English gynecologists, and was pre- 
ferred because it permitted examination to be made without 
danger of touching the tender structures at the anterior part of 
the vulva. This position was thought less vulgar, and it allowed 
the finger to follow more readily the curve of the sacrum and to 
reach with greater ease the highly situated cervix. Its chief 
advantage, however, is in permitting m.ore minute investigation 
of the lateral fornices of the vagina. In abdominal palpation it 
affords increased opportunity to recognize changes of position of 
tumors and displacements of the viscera, particularly of the 
kidney. 




-Dorsal Position. 



30 



GYNECOLOGY. 



54. The Semiprone or Sims' Position (Fig. 3). — The patient 
is placed upon the left side and chest, with the left arm behind 




Fig. 3.— Sims' Position. Proper Method of Holding the Speculum. 

her, the left leg partly extended, the right being flexed at a right 
angle to the body. The intra-abdominal pressure is neutralized. 




Fig. 4. — Genupectoral Position. Organs Shown in Outline. 



The mobility of the uterus is readily determined, replacement 
more easily accomplished, and some anteflexions recognized as 



DIAGNOSIS. 



31 



the organ falls forward that are not apparent in any other posi- 
tion. The chief value of the position is in the use ot the Sims' 
speculum. 

55. The genupectoral position (Fig. 4), also called the knee- 
chest position, is one in which the patient rests upon the chest and 
knees. The left side of her face rests upon her left hand. The 




Fig. 5. — Trendelenburg Position. 



thighs are at right angles to the surface of the table. The chief 
value of this position is in replacing a retrodisplaced uterus'^or 
prolapsed ovary, or for elevating from the pelvis a more or less 
impacted tumor. 

56. The Trendelenburg Position. — The patient lies upon her 
back and on a plane inclined at an angle of 45 to 60 degrees, with 



32 GYNECOLOGY. 

the feet and legs over a flap of the table (Fig. 5). Heavy patients 
should have additional support by the application of shoulder 
pieces. This position can be utilized for examination of the 
pelvic viscera, but it is of more service in some operations upon 
the pelvic contents, for with the patient in this position, the 
intestines recede and light enters directly into the pelvis. It is of 
special value in the inspection of the bladder through the urethral 
speculum or cystoscope. 

57. The erect position is of limited application. The patient 
stands with feet separated, with one hand resting upon the 
shoulder of the physician, while he sits or kneels before her and 
introduces the index-finger into the vagina. The chief value of 
this position is in determining the amount of downward displace- 
ment of the pelvic contents and in securing ballottement in the 
early stages of pregnancy. 



PELVIC EXAMINATION. 

58. Inspection. — The patient is placed in the dorsal position. 
(Section 52.) In the first examination of every patient a visual 
examination should always precede the practice of touch. By 
carefully arranging the clothing this can be done without shock- 
ing the sensibility of the most modest. It affords information as 
to the cleanliness of the patient ; the presence of pediculi ; venereal 
warts or sores ; malformations ; traumatisms ; eruptions upon the 
vulva; tumors of the labia majora; elongation and thickening of 
the labia minora; hypertrophy of the clitoris; elongated or ad- 
herent prepuce ; lacerations of the perineum ; presence of hemor- 
rhoids, ulcerations, or fissures ; urethral caruncle ; anomalies of the 
hymen; cystocele; rectocele; prolapse of the uterus; and the 
quantity and character of vaginal discharge. Inspection maybe 
a simple preliminary to the touch. 

59. Simple Touch. — The pelvic floor presents three apertures 
or perforations: the urethra, the vagina, and the anus — through 
either one or all of which an exploration may be made. The 
vagina is the route usually chosen as affording the best oppor- 
tunity for securing the most extended information. 

60. Preparation. — The hands should be carefully cleansed. 
Independent of any possible danger of conveying infection, the 
educated woman will be doubtful of the physician who proceeds 
in her examination with unclean hands and nails. The latter 
should be cut close. Either hand may be used in examination. 
In some cases it may be desirable to use first one and then the 
other. When the vagina is sufficiently roomy, two fingers should 
be introduced. This affords additional length and surface for 



PELVIC EXAMINATION. 33 

touch. The fingers should be lubricated with soap or some un- 
guent, such as carbolized alboline. The soap is preferable, for 
in washing it is removed with the secretions; but with some 
patients, however, it aggravates any existing irritation. 

6i. Procedure. — The physician with one hand separates the 
vulva in order to avoid carrying up the hair, and proceeds to make 
the digital investigation. Pressing back the perineum, the finger 
or fingers more easily enter, and without impinging against the 
anterior delicate structures. The unemployed fingers of the 
hand should be carried back extended, as closing them shortens 
the distance accessible to touch. (Fig. 6.) This procedure 
affords information as to the presence of cysts in the labia ; the 




Fig. 6. — Proper Position of Fingers for Examination. 

size of the vagina ; relaxation of its walls ; condition of its mucous 
membrane ; amount of secretion ; the contents and tenderness of 
the rectum; inflammation and projection of the urethra; tender- 
ness, prolapse, and distention of the bladder; and relation of the 
uterus to the vaginal axis. In its normal position the cervix 
looks backward, the axis of the uterus being nearly at right angles 
to that of the vagina. The situation, size, and density of the 
cervix are recognized. It may be normal, may be lacerated on 
one or both sides, or may present a number of fissures — a stellate 
laceration. Its lips may be soft and velvety, from enlarged 
papillae; nodular, from enlarged or cystic Nabothian glands; 
3 



34 



GYNECOLOGY 



widely everted and dense, from chronic inflammation following 
laceration; enlarged and indurated, from chronic inflammation or 
malignant infiltration; enlarged, friable, or excavated in epi- 
thelioma. The OS will be a slightly transverse depressed dimple 




Fig. 7 (also Fu 



109). — Half Section of the Pelvis with Patient Erect, Showing 
Normal Position of the Uterus. — {Deaver.) 



when normal, or when abnormal, will be fissured laterally, bi- 
laterally, through the anterior or posterior lip, or in a number of 
directions. It may be firmly closed or may stand open to such a 



PELVIC EXAMINATION. 35 

degree as to admit the finger. The spaces about the vaginal pro- 
jection of the uterus are known as the fornices. The posterior 
fornix is the deeper; the anterior is sHght. The resistance and 
density recognized indicate the existence or absence of inflam- 
mation. A mass in the posterior fornix, if continuous with the 
cervix, the axis of which is parallel to that of the vagina, is a 
retroversion of the uterus. If there is an angle between it and 
the cervix, the condition may be a retroflexion of the uterus, a 
tumor of the posterior uterine wall, an enlarged ovary or tube, or 
an inflammatory exudate. Digital examination also affords an 
idea of the mobility of the uterus, but the investigation is con- 
fined to the lower segment. 

62. Bimanual procedure, also called the conjoined manipu- 
lation, or vagino-abdominal touch, affords more definite infor- 
mation. In every examination the introduction of one or two 
fingers into the vagina should be associated with the application 
of the fingers of the other hand upon the abdomen. The external 
hand may be placed about midway between the symphysis and 
umbilicus, pressing downward upon the anterior abdominal wall. 
It may be moved from one side to the other, in order to examine 
the contents of the pelvis. This procedure enables us to outline 
the size, shape, density, and situation of the uterus, and to deter- 
mine the presence of growths in its walls and its relation to other 
pelvic growths or to inflammatory deposits. The normal tube is 
rarely palpable. When it is readily perceived, it is the result of an 
inflammatory condition. The ovaries are more easily recognized. 
To arrive at a deflnite conclusion in an obscure case, it is better to 
introduce into the vagina the fingers of the hand corresponding to 
the ovary to be palpated, as the extreme rotation necessary to 
bring the sensitive surface of the finger in contact with a small 
mass diminishes the sense of perception. (Fig. 8.) 

63. Difficulties. — The bimanual examination is rendered diffi- 
cult by a large deposit of fat in the abdominal wall and by 
rigidity of the abdominal muscles. The latter is sometimes so 
marked that the patient can not relax the muscles, and the deter- 
mination of the pelvic condition is unsatisfactory. When this 
is due to nervousness, much can be accomplished by allaying the 
patient's fears and securing her cooperation. Have her breathe 
with the mouth open, fill her lungs, and then expel the air, while 
the hand over the abdomen depresses the wall during expiration, 
and thus secures an outline of the pelvic organs. The procedure 
may sometimes be rendered less difficult by diverting the patient's 
attention through inquiries regarding other symptoms. When 
the resistance can not be overcome, or the sensitiveness arises 
from an infiammatory condition, or the abdominal walls are very 
fleshy, an anesthetic may be necessary. 



36 



GYNECOLOGY 



64. Virgins. — It is often a serious question to determine when 
an examination should be made upon a young unmarried woman. 
It should be the rule to avoid such an examination, unless the 
symptoms are of such a character as to indicate the existence 
of conditions which endanger her health. The regular occurrence 
of menstrual molimina, without the appearance of bloody dis- 
charge, after the age wdien puberty should be expected, must be 
considered an indication for a physical investigation. In many 





Fis:. 8. — Bimanual Examination. 



patients requiring a digital examination the procedure can be 
accomplished through the rectum. 

65. Rectal Touch. — (The rectal touch, recto-abdominal [Fig. 
9], rectovagino-abdominal, or rectovesical touch.) The routine 
practice of digital examination by the rectum in the first in- 
vestigation of a patient is to be commended. The finger should 
be carefully washed after removal from the vagina and before its 
introduction into the rectum, and vice versa. Neglect of this 



PELVIC EXAMINATION. 



37 



precaution may lead to a severe proctitis from the introduction 
of infectious material. The anointed finger, first directed for- 
ward, and after its entrance carried backward, is gently rotated. 
It enables us to recognize the condition of the rectum ; the pres- 
ence of fissures; hemorrhoids, ulcerations; contractions of the 
sphincter; sensitiveness of the coccyx; encroachment upon the 
bowel by the uterus ; the condition of the posterior surface of that 
organ; the presence of inflammatory exudate in the pelvis; 
malignant infiltration of the broad ligaments or peritoneum; 




Fig. 9. — Recto-abdominal Palpation. 



and the position of the uterus, when we desire to avoid a vaginal 
examination of the virgin. The rectal procedure promotes the 
replacement of the displaced organ. The correction of malposi- 
tions is facilitated by the introduction of the middle finger into 
the rectum and of the index-finger or thumb into the vagina. 
(Fig. 10.) The conjoined rectal manipulation is known as the 
recto-abdominal, the rectovaginal, the rectovagino-abdominal, 
or the rectovesical, according to the position of the fingers of the 
two hands. The absence or presence of the uterus in congenital 



38 



GYNECOLOGY. 



atresia vaginalis may be determined by rectovesical touch ; that 
is, the introduction of the finger into the rectum and of a sound 
(Fig. ii), bougie, catheter, or finger of the other hand through 
the urethra. It is rarely that it will be necessary to explore the 
bladder with the finger. 

66. Simon^s method consists in the introduction of the whole 
hand into the bowel, and is capable of affording additional in- 




Fig. lo. — Rectovagino-abdominal Palpation. Index-finger of one hand in the 
rectum, thumb in the vagina, and the fingers of the other hand over the 
abdomen. 



formation as to the condition of the pelvic organs. Such serious 
injuries have resulted from its practice, however, that it is now 
considered an unjustifiable procedure, unless the surgeon has an 
exceedingly small hand. 

67. Precautions. — It would be unwise to dismiss the subject 
of bimanual examination without a word of caution. The pro- 



PELVIC EXAMINATION. '39 

cedure should always be exercised with care not to do injury. 
Anxiety to arrive at a correct diagnosis may lead to rupture 
of a tubal collection or an ectopic gestation sac, and to the 
necessity for prompt operation to save life. I have seen two 
patients in whom examination has been followed by rupture 
of ectopic gestation sacs, with death in both from internal 
hemorrhage. 

68. Instrumental Examination. — The order generally recom- 
mended for the use of instruments has been: First, the use of the 
sound and then the speculum. The difficulty, however, in 
rendering the vagina sterile has justly led to the reverse procedure. 
The sound is a long, flexible instrument, twenty-five centimeters 
in length, two or three millimeters in diameter, terminating in a 
bulbous end, which generally has a slight elevation about six 



Fiof. II. — Rectovesical Palpation. Sound in Bladder. 

centimeters from its end, which indicates the normal length of the 
uterine cavity. For convenience in measurement its posterior 
surface is marked by a scale in inches or centimeters. The 
iftstrument should be perfectly smooth, having no notches or 
indentations which may serve to retain infection. It is made of 
silver, or copper (silver or nickel plated), and should be sufficiently 
flexible to admit of its being readily bent. The handle should be 
roughened upon one side so that the concavity of the instrument 
can always be determined. Such an instrument is known as 
Simpson's sound. Sims advocated the use of a finer and more 
flexible instrument, known as the probe. 

69. Probes may also be made of whalebone. The uses of the 
sound or probe are to ascertain the patenc}^ of the cervical canal, 



40 



GYNECOLOGY. 



the depth of the uterus, its width or capacity, the thickness of its 
walls, the presence of intra-uterine tumors, the condition of the 
mucous membrane, the direction of the uterine canal, and the 




Fig. 12. — Simpson's Sound. 

mobility of the uterus. In treatment it has been used to replace 
the displaced uterus. The experienced physician will be able 
to obtain much of this knowledge fully as effectually by the 




Fig. 13. — Sims' Probe. 

bimanual examination, and in the majority of cases the dis- 
advantages of the instrument greatly outweigh the value of the 
information obtained by its use. It affords knowledge as to the 
patency of the canal which can not otherwise be determined ; in 



Fig. 14. — Whalebone Probe. 

all other instances the omission of its use is preferable to its 
employment. It is true it is capable of affording information 
as to the direction of the uterus when the situation of that organ 
is rendered doubtful by the presence of inflammatory exudate. 



:T^o-7grzn./^/.^,/.Az„/^z.;.^z././^^fc/„^^^^^/U^ 



Fig. 15. — Spring Probe Covered with Rubber. 



but in such cases its use is contraindicated. Our inability to 
secure an aseptic vagina should lead to the introduction of the 
instrument through the speculum, and then only after the vault 
of the vagina has been carefully mopped with absorbent cotton 



PELVIC EXAMINATION. 



41 



wet with a solution of bichlorid, i : 2000, or, better, of formalin, 
1 : 1000. It is almost impossible to introduce the instrument 
without injuring the mucous membrane of the uterine cavity, an 
injury which will afford a favorable culture-field for the develop- 
ment of germs which are found in the vagina, or, exceptionally, 
even in the cervical canal. Such injuries explain the inflam- 
matory irritation following its use, and still further demonstrate 
the wisdom of discontinuing its employment for replacement of 
the uterus. When it seems desirable to use the sound without 




Fis:. 16. — Introduction of the Sound. 



the Speculum, the vagina should be previously scrubbed and two 
fingers introduced to the cervix, by which the sound is guided 
into the os. (Fig. 16.) No force should be employed and the 
instrument should have such a curve as will permit it to pass 
readily in the direction which a bimanual examination has demon- 
strated should be that of the uterine cavity. 

70. Precautions. — The date of the last menstruation must 
be known, and the use of the instrument should be avoided when 
there is the slightest suspicion of pregnancy. It should not be 



42 GYNECOLOGY. 

employed in the presence of acute inflammation or when inflam- 
matory exudate or old inflltrations can be determined. Its em- 
ployment in a case of malignant disease may lead to dangerous 
hemorrhage. In the uterus softened and rendered friable by 
inflammation the sound may penetrate its wall and enter the 
abdominal cavity. This accident produces no inconvenience 
unless the instrument carries infection. The sound may also 
pass into a Fallopian tube. This is more likely to occur in a 
bic ornate uterus. The instrument should be scrupulously clean 
and should be removed from a five per cent, solution of carbolic 
acid prior to its use. After its use in a case of suspicious char- 
acter the instrument should be sterilized by heat. 

71. Speculum.— A patient placed in the dorsal position, with 
the limbs separated, reveals the mons veneris, with the larger 
labia. The latter are separated by a cleft or slit — the rima 
pudendum. Frequently the labia minora are elongated, and 
they, with the clitoris, are prominent. The posterior commissure 
may have been injured, and, instead of a slit, we will have a 
triangular opening, through the posterior part of which projects 

the vaginal wall. In lac- 
erations of the pelvic floor 
its posterior segment may 
be drawn back, permitting 
one or two inches of the 
vagina to be inspected. By 
hooking back the vagina 
Fig. 17.— Ferguson's Speculum. with two fingers the cervix 

can frequently be seen. The 
necessity for satisfactory inspection of the uterus led to the in- 
vention of the speculum. A great variety of instruments for 
this purpose have been devised, but all may be classed in two 
divisions : the tubular and the valvular. 

72. The tubular speculum, known as the Ferguson speculum, 
may be made of glass, wood, rubber, celluloid, or metal. The 
instrument is cylindric, the external end with a flange, the inter- 
nal beveled, and having one long side. (Fig. 17.) Glass instru- 
ments may be made of milk-glass (Fig. 18), as the German 
speculum, or such covered with quicksilver, and over this a 
coating of pitch or rubber. Such specula can not be sterilized 
by heat; glass is brittle, easily broken, and is subsequently use- 
less. They are very serviceable in making applications to the 
cervix, but only the wooden instruments are utilizable for the 
use of the actual cautery. The application of medicaments to 
the uterine canal, or the use through it of the sound, are to be 
condemned. The tubular speculum is not self -retainable. Its 
range of application is so limited that it is now infrequently 




PELVIC EXAMINATION. 



43 




Fie. li 



-Milk-glass Specula. 



used. To introduce this instrument the physician separates the 
labia with the left hand and holds the speculum with the right 
thumb and middle finger on either side and the index-finger 
upon its upper surface. The longer side is placed against the 
posterior commissure of the 
vulva, which is depressed, 
and the speculum is pushed 
upward and backward, at 
the same time rotating 
the instrument so that its 
shorter side does not im- 
pinge against the tender 
anterior structures. The 
situation of the cervix has 
been previously located by 
the touch. If the cervix is 
not brought at once into 
the field of the speculum, 
it can usually be exposed 
by rotating the instrument. 

When this procedure fails, it may be drawn into the field by a 
tenaculum. If the cervix is large, only a part of it can be ex- 
posed at one time, and consequently a distorted idea of the 
condition is frequently obtained. 

73. Valvular Speculum. — The valvular speculum may have 
one or more valves, and are called univalve, bivalve, tri valve, 
and qua dri valve, according to the number of blades. They 
afford a much better exposure and are self -retaining ; therefore, 

they have largely 
supplanted the tub- 
ular instrument. 
The quadrivalve in- 
strument is now 
rarely used, as it 
affords but slight 
additional advan- 
tage over the bi- 
valve, and besides 
it is difficult to 
keep clean. The 
Nott (Fig. 19) and 
Nelson specula have three blades and afford an opportunity to 
inspect the anterior vaginal wall. The bivalve speculum is the 
most satisfactory for general use. Of the great variety of 
specula, Higbee's (three sizes) (Fig. 20), Talley's (Fig. 21), and 
Goodell's (Fig. 22) are probably the most satisfactory. The 




Fig. 19. — Nott's Speculum. 



44 



GYNECOLOGY. 



blade should be from 7.5 to 11 centimeters in length. When 
the vaginal portion of the cervix is short, the Higbee speculum, 




Higbee's Specula (three sizes). 




Fig. 21. — Talley's Speculum. 



which has a long posterior blade, will not expose the os. In such 
cases the Goodell or Talley specula, with blades of equal length, 

are better. The speculum 
is introduced by separating 
the vulva with the fingers 
of the left hand, while the 
instrument, held in the 
right, is introduced with 
its transverse diameter par- 
allel to the long diameter 
of the vulva. As the wid- 
est diameter of the vagina 
is at right angles to that of 
the vulva, the instrument 
is rotated and carried upward, directing the blades behind the 
cervix, the position of which has been previously determined by 
a digital examination. 
As the blades are sep- 
arated the cervix is 
generally exposed. In 
marked anteversion it 
may be necessary to 
use a tenaculum to 
bring the cervix into 
view. The speculum 
is a therapeutic in- 
strument, although it confirms the diagnosis which has been made 
by digital examination. 




Fig. 22. — Goodell's Speculum. 



PELVIC EXAMINATION. 



45 



74. The univalve or duck-bill speculum (Fig. 23), introduced 
by Sims, is used with the patient in the semiprone position. The 
instrument has two 
blades at either end of 
a handle, which are 
about 10 centimeters 
long, the smaller blade 
being 1.5 centimeters 
and the large blade 4 
centimeters in width. 
To introduce this in- 
strument the physi- 
cian raises the but- 
tock, passes the blade 
with its width parallel 
to the vulva, and after its entrance rotates it with the handle 
directed backward. The assistant then holds the other blade 




Fig. 23. — Sims' Speculum. 




4 



Fig. 24. — Proper Method of Holding Sims' Speculum. The cervix brought into 
view with the tenaculum. 



with the right hand, using the instrument as a retractor. (Fig. 
24.) His elbow is held against his hip, while the left arm rests 



46 



GYNECOLOGY. 



Upon the patient, the hand elevating the buttock. Care must 
be exercised to follow the curve of the sacrum or the instrument 




Fig. 25.- — Sims' Depressor. 



Fig. 26. — Goodell's Tenaculum. 



will slip out. As the perineum is drawn back the vagina is bal- 
looned by the atmospheric pressure and the cervix and upper 

vagina are exposed. 
When the vagina is 
large, with relaxed walls, 
the cervix may be ob- 
scured from view. The 
depressor (Fig. 25) to 
push back the anterior 
wall or a tenaculum 
(Fig. f 2 6) hooked into the 
cervix will overcome the 
difficulty. The univalve 
speculum affords a better 
exposure of the cervix 
and upper portion of the 
vagina than any other 
form of instrument. Its 
particular disadvantage 
is that it is not self -re- 
taining, and in office practice requires the assistance of a nurse. 




Fig. 27. — Self-retaining Sims Speculum. 




Fig. 28. — Simon's Retractors. 

Various devices (Fig. 27) have been instituted to render it self- 



PELVIC EXAMINATION. 



47 



retaining, but they require considerable time for their use. In 
operating with the patient in the semiprone position, the irrigat- 
ing fluid and blood run forward, between the patient's limbs, and 
hence render it difficult to keep her person and clothing clean. 
The Sims speculum can be used with the patient in the lithotomy 
position, but it is uncomfortable to hold. The Simon posterior 
and side retractors serve a similar purpose. (Fig. 28.) The 




Fig. 29. — Edebohls' Speculum. Fig. 30. — Edebohls' Speculum in Position. 

perineal retractor known as the Edebohls speculum (Fig. 29) is 
the most satisfactory. With the patient upon her back, and the 
limbs acutely flexed, the perineum is retracted and held back 
by a weight attached to the instrument. (Fig. 30.) The cervix 
and the upper and anterior vagina are thus exposed to manipu- 
lation. 




Fig. 31. — Double Tenaculum Forceps. 



75. Uterine Fixation and Downward Traction.— Reference 
has already been made to the use of the tenaculum to bring the 
cervix into the field of the speculum. The same instrument, or, 
better, a double tenaculum known as bullet-forceps (Fig. 31), 
guided to the cervix by the finger, may be used to fix the organ, 
or in some cases to exert traction (Fig. 32) upon it during digital 



48 GYNECOLOGY. 

examination. Such a procedure enables us to examine through 
the rectum the whole posterior surface of the uterus and even to 
pass the finger over its fundus. It is utilized in replacing the 
retroverted and retroflexed organ and in differential diagnosis 
of abdominal and pelvic growths. 

76. Dilatation of the Uterus. — It is frequently necessary to 
explore the cavity of the uterus, either to complete the diagnosis 
of a condition rendered probable by other procedures or as a 
preliminary to an operation. The method of operation may be 
divided into two classes: (i) Bloodless — tents, divulsion, and 
gradual dilatation; (2) by incision of the external os and bilateral 
incision of the cervix. Before the practice of any of these pro- 
cedures the presence of inflammation in the organ or vestiges of 




Fig. 32. — Traction upon Uterus with Double Tenaculum during Digital Exam- 
ination by the Rectum. 

inflammatory exudate about it should be excluded. The existence 
of such conditions presents an element of serious danger. 

77. Dilatation by Tents. — The use of tents was formerly very 
popular and a general method of dilatation. The materials used 
for this purpose were sponge, laminaria, tupelo, slippery elm, 
decalcified ivory, and gentian root. The sponge has the greatest 
dilating power, but is the most difficult to render aseptic and to 
maintain in that condition. The frequent unfortunate sequels 
that followed their use have largely led to their discontinuance. 
The laminaria (Fig. 33) and tupelo tents are the most used. The 
former may be introduced in nests. Their dilating power is 
enhanced by having them hollow. A number of small ones to fill 
up the canal is to be preferred to one large tent. They may be 
rendered aseptic by subjection to a dry heat of 250° F. The 



PELVIC EXAMINATION. 



49 



tent should be placed in an envelope before its introduction into 
the sterilizer, and the envelope should be broken only when it is 
to be used. The tents may also be rendered safe by immersion 
prior to their use in a saturated solution of iodoform in ether. 
Pozzi advocates their immersion in equal parts of carbolic acid 
and alcohol. The vagina and cervix should be carefully cleansed 




Hollow Laminaria Tent. 



with an antiseptic solution; the cervix is seized through the 
speculum with bullet -forceps, while the tents are held in (Fig. 34) 
dressing forceps, and introduced, one after another, until the 
canal is filled. Care must be exercised to mold the tents to the 
curve of the canal, and no force should be employed in their 
introduction. The tents should project from the external os, 




Fig. 34. — Uterine Forceps — Dressin 



and should be held in place by a tampon of iodoform gauze. 
They should be removed at the end of ten or twelve hours. They 
are removed by pulling upon a string fastened to the end of the 
tent. Removal is sometimes rendered difficult by irregular 
dilatation; the internal os, being more resistant, causes an hour- 
glass-shaped distention. (Fig. 35.) The tent is removed by 




I^ig- 35- — Dilated Tent Showing Constriction from Internal Os. 



placing the finger against the cervix during traction. The ir- 
regular dilatation is less likely to occur with a tupelo tent, though 
its dilating power is not so great. Pain during the dilatation 
can be relieved by the use of from two to five grains of acetanilid 
to i of a grain of codein. The removal of the tent 



or from I 



50 



GYNECOLOGY. 



should be followed by careful antiseptic irrigation, after which 
another tent or series of tents may be introduced. The use of 
the tent affords an opportunity to make a digital exploration of 
the uterine cavity, and is of advantage in small submucous 




Fig. 36. — Ellinger's Dilator. 




Fig. 37- — G-oodell's Modification of Ellinger's Dilator. 



fibroids, in suspected epithelioma, and in retained products after 
abortion. 

78. Divulsion consists in the rapid dilatation of the uterine 
canal by the various dilating instruments. The preferable in- 
struments are the parallel bar dilators, such as the Ellinger 
(Fig. 36), with the Baer and Goodeli modifications (Fig. 37); 

the latter, with its 
roughened blades, is a 
powerful instrument. 
The vagina and cer- 
vical canal are care- 
fully cleansed, and 
through the specu- 
lum the cervix is 
seized with a dou- 
ble tenaculum! and 
stretched with small 
dilators, and subse- 
quently with the 
large instrument to 
the extent of two or 
three centimeters, if desired. The principal objection to the pro- 
cedure is that the pressure is confined to the lateral surfaces of 
the cervix and, therefore, may lead to laceration. 

79. Gradual dilatation is accomplished by the use of graduated 




Fig. 38.— Pratt's Dilators. 



PELVIC EXAMIXATIOX, 



51 



bougies, made of steel or hard rubber. The former are prefer- 
able, as they can be sterilized by heat. The Pratt series of 
bougies, Avhich have two bougies to each handle, making eighteen 
in the set, the maximum being No. 43, Avill be useful. (Fig. 38.) 
Each bougie is two millimeters larger than the preceding. After 
thorough cleansing of the vagina and cervix the Edebohls specu- 
lum is introduced, the cervix is seized with vulsellum or double 
tenaculum, and the bougies are used one after another, up to the 
largest size. (Fig. 39.) Care should be exercised not to punc- 
ture the uterine wall. This accident is more likely to occur in 
acute flexions ; the point of the instrument makes so much pres- 




Fig. 39. — The Method of Dilatation with the Graduated Bougies. 



sure upon the thin convex wall near the flexion that it finally 
ruptures. It is sometimes advised to precede this method by the 
use of a tent, but it does not seem necessary. The dilatation 
can be accomplished by the bougies in shorter time than by 
divulsion. 

80. Incision of the Cervix. — The external os, when very rigid, 
or when the cervical canal is partly dilated by an extruding 
fibroid, may be incised. This procedure may be resorted to for 
abortion in the absence of proper dilating instruments. An 
incision from i centimeter to 1.5 centimeters should be made 
with scissors upon either side. As the ordinary scissors slip off, 



52 GYNECOLOGY. 

the Kuchenmeister scissors (Fig. 40) are more effective. The 
procedure is most readily accompHshed by grasping each hp with 
a double tenaculum and incising on either side with a knife. The 
operation completed, the incised cervix should be closed with 
sutures. 

81. Complete bilateral incision of the cervix is rarely indicated, 
as other measures of less severity can be utilized. The operation 
may be supplemented, if necessary, by ligation of the uterine 
arteries. The vessels may be secured by drawing the cervix to 
one side and passing a ligature with a strongly curved needle. 
Care should be exercised to keep close to the uterus and not to 
carry the ligature forward of a line tangent to the anterior cir- 
cumference of the cervix, in order to avoid ligation of the ureter. 
A second ligature is passed upon the opposite side, when the 
cervix can be incised with a knife to the vaginal fornix on either 
side without danger of hemorrhage. Although generally advised 
that ligation should precede incision, it is unnecessary. Hemor- 
rhage does not always occur, and when it does, the bleeding 




Fig. 40. — Kuchenmeister's Scissors. 

vessels can be seized with forceps and then ligated. If the finger 
can not be passed through the internal os, the canal can be still 
further enlarged with a probe-pointed bistoury. After ex- 
ploration or operative procedure the cervix should be carefully 
sutured. The lateral ligatures should be removed in two or three 
hours, or in a shorter time if there is any reason to fear that the 
ureter has been ligated. The prolonged retention of the ligatures 
would result in sloughing of the vagina. 

82. Dilatation by Gauze Packing. — Vulliet has devised a pro- 
cedure for prolonged dilatation, which he denominates a ' ' method 
of dilatation by progressive plugging." It consists in repeated 
plugging of the cervical canal with medicated gauze. Strips of 
gauze, after the uterus has been carefully cleansed, are packed 
into the cervical canal until it is completely filled. These are 
permitted to remain for forty-eight hours, when they are re- 
moved, and if the uterus is not then dilated sufficiently to admit 
the finger, the cavity is again cleansed and packed. Pieces of 



PELVIC EXAMINATION. 53 

compressed sponge have been used for a similar purpose, and, 
from their increase in size under moisture, are probably more 
effective. The only source of anxiety is the uncertainty as to 
their being absolutely sterile. This plan of procedure may be 
carried over a series of days or weeks, without inflammatory re- 
action. It is, however, not effective in cases of rigid cervix, 
and the same purposes may be accomplished by a more rapid 
dilatation. 

83. Cureting. — The curet in doubtful cases may afford 
sufficient material for a microscopic examination to make the 
diagnosis certain. (Fig. 41.) 

84. Microscopic Examination. — The most careful examination 
by touch and sight Avill often fail to reveal minute tissue changes, 
which are of such ultimate importance as to render their prompt 
discovery vital to the interests of the affected individual. The 
microscope in such conditions is a valuable diagnostic agent. To 
its use we are indebted for our knowledge of the normal structures 
of the genital tract. It has revealed the character and variety 
of the epithelium, its situation and relation to the glandular 





Fig. 41. — Douche Curet. 

structure — information which could not be otherwise procured. 
It is, therefore, reasonable to consider that it would be equally 
valuable in demonstrating pathologic alterations in the course 
and progress of disease as impressed upon the tissues, and conse- 
quently prove a valuable means of diagnosis, upon which can be 
based definite ideas of prognosis and suitable methods of treat- 
ment. 

85. Microscope. — ^Microscopic examination confirms the sus- 
picion of a disease awakened by subjective symptoms, and the 
microscopic appearance of tissue reveals the extent, stage, and 
progress of the disease, and also demonstrates any error oc- 
casioned by misleading symptoms or unusual signs. The micro- 
scope, associated with bacteriologic cultures, is effective in con- 
firming the diagnosis of gonorrhea, tuberculosis, sepsis, typhoid 
fever, and between benign and malignant neoplasms. It affords 
a certain means of differentiation between malaria and obscure 
forms of sepsis. The microscopic study of the blood is of special 
value in the recognition of various forms of anemia, and affords 
information which is useful in determining the prognosis. A 



54 GYNECOLOGY. 

differential blood count is frequently confirmatory of a given 
diagnosis of inflammatory, suppurative, or malignant disorders, 
and it is, therefore, especially valuable in making accurate 
diagnoses. The more accurate the diagnosis, the more certain 
the prognosis, and, therefore, the more hopeful the method of 
treatment. When we consider the rapid changes that take place 
in malignant disease, the extension along the course of lymph 
channels to the lymph glands, subsequently involving the tissues 
which are inaccessible, we can appreciate the importance of any 
method which will afford early knowledge of the serious character 
of the disease. The method of determining the diagnosis by 
watching the course of the disease can not be too strongly con- 
demned. Not infrequently such assured recognition of the dis- 
ease is associated with the knowledge that the time for successful 
operative treatment has elapsed. 

86. Material. — The material upon the investigation of which 
the diagnosis is based is procured by test excision or test cureting 
of the parts accessible. The tissues excised should not be con- 
fined to the diseased structure, but should comprise an area which 
will show the transition from healthy to diseased tissue. When 
the disease is within the uterine cavity, the tissue can be secured 
by the curet. The cureting is more effectively done after dilata- 
tion of the uterus either by graduated bougies or, preferably, by 
tents. If the latter are employed, the finger can be introduced 
and act as a guide to the curet. Occasionally portions may be 
broken off by the finger or masses may spontaneously discharge. 

87. Methods.— A dangerous operation, the future comfort of 
the patient, and, indeed, her chances for life will often depend 
upon an examination of the specimens secured. It is, therefore, 
necessary to employ all the finer methods of microscopic technic 
at our disposal. The excised tissue as well as the particles secured 
by cureting should be washed in running water and carefully 
inspected with the naked eye, and also with a magnifying glass; 
by which its color, consistence, and general structure can be 
recognized. During this examination it can be determined what 
course shall be pursued in fixing and preparing for a more com- 
plete examination. As the tissue will undergo marked change in 
this process of fixing, it is wise that a drawing should be made 
and the direction in which the future sections are to be cut deter- 
mined. Abel advises that excised portions be divided so that 
one part can be examined while fresh, and the other be prepared 
for finer sections. Cureted material, unless in large quantities, 
should be at once placed in a fixing solution. 

The fresh specimens are at once placed in normal salt solution 
which preserves the individual elements in their original form. 
The particles may be examined as teased specimens, or be cut with 



PELVIC EXAMINATION. 55 

the freezing microtome. The latter course is preferable, as it inter- 
feres less with the relations of the structures, and, consequently, 
permits a more correct judgment as to the condition. 

By teasing the elements are separated from each other when 
it is impossible to decide whether the surface epithelium sends 
processes into the tissues or whether a simple hyperplastic or 
destructive process exists — points of the greatest importance in 
arriving at a correct diagnosis. 

The fresh specimen should be cut with the freezing microtome, 
but the sections should not be too thin, as they are likely to 
tear in subsequent manipulation. 

Each section is removed from the knife with a camel' s-hair 
brush and placed in distilled water. To prevent the sections from 
being torn in transmission to the slide, it is better that the latter 
be pushed under the section as it swims in the fluid and be gently 
held with a glass rod. 

The section, having been carefully spread upon the slide, is 
then covered with a fine cover-glass. The latter is grasped at one 
edge with forceps, the other side brought at an acute angle upon 
the fluid covering the surface of the slide and gently released, re- 
moving the superfluous fluid with blotting-paper. The section 
can now be studied with high or low power, but when unstained is 
best placed upon a dark under layer. 

Specimens so studied have the advantage that we see the cells 
as they were during life, and the character of the normal tissue 
or any degenerative process can thus be recognized. 

The specimen may be subjected to various microchemical 
reactions which will afford valuable information. The section 
may be rendered more transparent by a drop of a 2 or 3 per cent, 
solution of acetic acid placed under the edge of the cover-glass. 
A piece of blotting-paper held at the other side causes it to 
penetrate the section quickly. Fatty tissues may be removed 
by the similar use of alcohol, chloroform, or ether. 

Elastic flbers are rendered prominent by caustic soda in a 
I to 3 per cent, solution. A marked swelling of the contractile 
elements of the smooth and striated muscles and of the nuclei 
occurs, and the horny substance becomes transparent. A 33 
per cent, solution of caustic potash is especially valuable as a 
preservative. Red blood-cells preserve their form well in such a 
solution. 

Infarctions or plethora of blood-vessels are in no way so well 
observed as in fresh specimens. They may be permanently pre- 
served by replacing the salt solution with glycerin, or preferably 
with a 55 per cent, solution of potassium acetate. Pick's method 
presents the best procedure for preserving frozen specimens, and 
consists in the use of alum-carmin combined with formalin. 



56 GYNECOLOGY. 

The alum-carmin of Grenach (4 to 5 per cent, of carmin) is 
added to Schering's formalin 10 to 100, which should be kept in 
a dark-colored bottle. 

Pick's process is as follows: 

1. Preparation of the frozen section with Jung's microtome. 

2. Transference of the section into a 4 per cent, formalin 
solution for one-fourth minute. 

3. Formalin-alum-carmin, two to three minutes. 

4. Washing in water, one-half minute. 

5. Eighty per cent, alcohol, one-half minute. 

6. Absolute alcohol, ten seconds. 

7. Carbol-xylol, one-half minute. 

8. Canada balsam. 

Coplin says that his experience convinces him of the necessity 
for thoroughly fixing all tissues before attempting to section 
them, otherwise the results are always open to criticism, because 
the distortion incident to congelation masses; maceration; and 
the difficulty of removing the infiltrates produce conditions which 
would mislead the most experienced observer. He advises the 
following fluids: 

1 . Flemming's solution, which consists of a i per cent, aqueous 
solution of chromic acid, 25 volumes; i per cent, aqueous solution 
of osmic acid. 10 volumes; i per cent, aqueous solution of acetic 
acid, 10 volumes; water, 55 volumes. 

All water in stock solutions and final mixtures must be dis- 
tilled. Small pieces (five-tenths — i cm. cube) will undergo 
sufficient fixation in from one -half to two hours. After this 
process is complete they should be washed in running water for 
six hours. 

2. Hermann's solution: i per cent, aqueous solution of platinic 
chlorid, 15 volumes; 2 per cent, aqueous solution of osmic acid, 
2 volumes; glacial acetic acid, i volume. 

3. He regards corrosive sublimate solution as the most useful 
fixing agent for general use, although for pure cell study the first 
two solutions are probably better. It consists of 125 gm. of 
corrosive sublimate dissolved in a liter of 0.5 per cent, solution 
of sodium chlorid in water. Small pieces fix in this solution in 
from one-half to two hours. The used solution is filtered back 
into the stock solution, while the hardened tissue is washed in 
water, or preferably in 70 per cent, alcohol. This solution is of 
advantage because of its cheapness, keeping qualities, and 
simplicity of technic. 

In the process of fixing with any of the plans, the quantity 
of fluid should several times exceed the volume of tissue to be 
fixed. 

It is important for purposes of diagnosis that the tissues 



PELVIC EXAMINATION. 57 

should not only be properly fixed, but that sections should be 
made with as little disturbance of cell relation as possible. At- 
tention must also be given as to the direction in which sections 
shall be made through the tissues. Sections parallel with the 
surface of a mucous membrane are of but little value, as they cut 
across glands and aft'ord no indication of the true character of 
epithelium. The most serviceable are the vertical or slightly 
oblique. 

Embedding. — A small piece of tissue may be prepared for 
section-cutting by being embedded in either gelatin, celloidin, or 
paraffin. 

Glycerin-gelatin. — Ten grams of the finest gelatin are placed 
in a clean vessel and covered with water. After four to six 
hours the water is poured off, and the mass liquefied by a mod- 
erate heat. While stirring with a glass rod, ten grams of glycerin 
and five drops of carbolic acid are added, and the mixture left 
in a wide-mouthed bottle. To embed a specimen, a piece of 
this mass is taken and liquefied by heat. A thin layer is poured 
upon the surface of a cork, the specimen placed upon it, and then 
covered with a mantle of gelatin which soon becomes hard. 

After being immersed in absolute alcohol for twenty-four 
hours good sections can be made. 

Celloidin. — The specimen is placed for twenty-four hours in 
absolute alcohol, and the same length of time in sulphuric ether. 
It then remains twenty-four hours in a tight bottle containing 
thin celloidin. At the end of this period it is placed in a thick 
solution, a small opening being left so that the alcohol and ether 
evaporate very slowly. In a few hours a semi-solid mass has 
formed, a block of which containing the specimen is cut out, 
fastened with thick celloidin upon cork or wood, after which 
it remains for twelve hours in a 70 to 80 per cent, solution of 
alcohol, when it has the proper consistence for section-cutting. 

Paraffin. — Abel prefers to stain the specimen preparatory to 
embedding in paraffin. The specimen, hardened in alcohol, is 
placed in the staining solution. This may be Bohmer's hem- 
atoxylin, eosin, or safranin. It should remain in a well-filtered 
solution two to eight days, according to its thickness. It is 
removed from the staining solution to 70 per cent, alcohol for 
twenty-four hours, then is dehydrated in absolute alcohol. It is 
placed in xylol for twelve hours to prepare it for saturation with 
paraffin. The specimen is placed in a mixture of equal parts of 
xylol and paraffin, in which it remains for twenty-four hours, 
subjected to a continuous temperature of 37° C. in a paraffin 
oven, after which it is kept in paraffin at a temperature of 48° 
to 50° C. The latter is then permitted to solidify at the room- 
temperature, when a paraffin block of suitable size containing the 



58 GYNECOLOGY. 

specimen is cut out and fastened to a cork or a piece of wood with 
paraffin, after which it is ready for cutting. 

The sections thus secured are thinner than those secured by 
any other method. 

Section-cutting. — Sections are preferably cut with a microtome 
and should be of equal thickness. A thickness of fifteen to 
tAventy microns will be satisfactory. 

The sections are conveyed with a camel' s-hair brush to a basin 
containing dilute or absolute alcohol ; the celloidin sections to 
a 70 per cent, solution of alcohol, the gelatin sections to absolute 
alcohol. The sections are very much shriveled by the alcohol 
and should be placed in water for several minutes before being 
transferred to the staining fluid. 

The paraffin sections can not be transferred from one vessel 
to another ; it is better to treat them on the slide. Abel applies 
one drop of a solution of collodion in alcohol upon a slide, and 
upon this the section, pressing it down with filter-paper. The 
paraffin is dissolved out with xylol, and covered with equal parts 
of xylol and Canada balsam, and over this the cover-glass is 
carefully placed. 

Staining. — We will consider only those methods which are 
most effective in rendering prominent the histologic structures we 
are desirous of utilizing in the diagnosis. Picrolithiocarmin and 
hematoxylin are both very satisfactory. 

The picrolithiocarmin, introduced by Orth, is prepared by 
uniting one part of lithiocarmin (a cold saturated solution of 
lithium carbonate in which carmin powder has been dissolved in 
the proportion of 2.5 grams of the latter to 100 grams of the for- 
mer solution) with two parts of a saturated solution of picric 
acid. This stain is best suitable for specimens which have been 
hardened with alcohol. The section is placed in the staining 
solution by a spatula and remains five to ten minutes, from which 
it is conveyed for one to two minutes to a solution of alcohol 
(70 per cent.) one hundred parts, hydrochloric acid one part, then 
washed in dilute alcohol and dehydrated in absolute alcohol. 
The specimen is made clearer by oil of cloves, oil of bergamot, or 
xylol. It is conveyed to the slide and spread out free of folds. 
It is then mounted in Canada balsam. Horny cells, fibrin, 
hyaline substances, and red blood-corpuscles take on a yellow 
color. The nuclei of the epithelium become a pale pink, fibrillar 
tissue remains undyed, affording a clear picture of the specimen 
stained. 

Hematoxylin stain is prepared by dissolving one gram of 
hematoxylin in 30 grams of absolute alcohol. To a solution of 
powdered alum (0.5 to i gram in distilled water 30 cm.) the above 
preparation is added drop by drop and shaken until the fluid 



PELVIC EXAMIXATIOX. 59 

takes a deep violet color. It is left for several days in a wide- 
necked bottle uncovered, when it becomes darker. It should be 
carefully filtered before being used. 

Celloidin-embedded sections remain longer (ten to twenty 
minutes, according to size and thickness) in the solution than 
the ordinary alcoholic sections, and are placed in alcohol con- 
taining h3^drochloric acid until they begin to assume a red tint, 
from Avhich they are removed to 70 per cent, alcohol. They are 
placed in absolute alcohol until the mantle of celloidin begins to 
curl. Care must be exercised that all the celloidin is not dissolved 
or the finer sections would fall to pieces. The section is made 
transparent in oil of bergamot or in xylol. Should the celloidin 
mantle at this stage become cloudy or milky, the section should 
be placed in absolute alcohol until it clears. With a spatula the 
section is placed upon a slide and mounted in xylol-Canada 
balsam after removing the oil with filter-paper. This method 
gives splendid staining of the nuclei, the protoplasm is slightly 
stained, the celloidin not at all. The diagnosis of malignant 
conditions is greatly enhanced by staining the elastic fibers. 
For this purpose Taenzer's orcein stain is employed. The 
sections are taken from water and kept in this solution from six 
to twelve hours or longer (Griibler's orcein 0.5, alcohol 40.0, aq. 
dest. 20.0, hydrochloric acid gtt. xx) , then placed for a few seconds 
in hydrochloric acid alcohol (hydrochloric acid o.i, 95 per cent, 
alcohol 20.0, aq. dest. 5.0), where they become differentiated and 
are washed in water. After five to ten minutes' dehydration in 
absolute alcohol, they are cleared in oil and mounted in Canada 
balsam. 

The elastic fibers appear as an intense red upon a pale pink 
background. 

Wei^erfs fiichsin-resorcin stain is made by taking 200 c.c. of 
the following mixture: Resorcin 2.0, fuchsin i.o, distilled water 
1 00.0, and bringing it to a boil in a porcelain vessel, when 25 c.c. 
ferri liq. sesquichlor. (German Pharmacopeia) are added, the 
whole boiled while stirring for two to five minutes longer. The 
muddy mass thus formed is permitted to cool and then filtered. 
The portion which runs through the filter is thrown away, and 
the deposit left upon the filter until it ceases to drip. 

The filter with its contents is removed from the funnel, 
placed in a bowl, and boiled under constant stirring with 200 c.c. of 
94 per cent, alcohol. While boiling the filter-paper is removed 
and the solution is permitted to cool, after which it is filtered and 
the filtrate brought to 200 c.c. by the addition of alcohol. After 
adding 4 c.c. of hydrochloric acid the solution is ready for use. 

The sections are placed in this solution for twenty minutes 
to one hour, washed in alcohol, and cleared in xylol. 

The elastic fibers are stained dark blue, almost black, on a 



60 GYNECOLOGY. 

quite light background. The nuclei may be stained with a 
carmin preparation. 

88. Failure. — Examination may fail to reveal the true 
character or presence of disease, because the section was made 
through the adjoining healthy tissue. 

89. Bacteriologic Cultures. — Any discussion of the usefulness 
of the microscope as an agent in the diagnosis of disease would 
be defective which did not recognize the influence of micro- 
organisms in the development of diseased processes and consider 
the best methods of securing their ready recognition. We are 
coming more and more to recognize that to intelligently battle 
with the results of disease, we can not be too well informed as to 
its cause. The position of micro-organisms as an important 
factor in the production and propagation of disease is now too 
universally acknowledged to admit of further question. The 
more important micro-organisms against which our energies must 
be directed are the gonococcus, the staphylococcus pyogenes 
aureus, staphylococcus albus, the streptococcus pyogenes, the 
bacillus coli communis, and the bacillus tuberculosis. 

90. The gonococcus of Neisser, found in gonorrheal discharge, 
is difficult to cultivate outside of the body. It exists in the form 
of a diplococcus, penetrates the protoplasm of pus cells, and 
rapidly multiplies therein. (Fig. 42.) The cocci develop in 
cellular epithelium, such as is found in the male and female 
urethra, Bartholin's glands, the uterine cavity and the con- 
junctiva. The baneful influence of this micro-organism has been 
regarded as the cause of nearly all the inflammations of the tubes 
and ovaries. The gonococci may be sought in the secretions or 
in sections of the tissues. From the former, glass slide or cover- 
glass specimens of the secretion are made by spreading it and 
letting it dry. The specimens are first dried in the air and subse- 
quently carefully drawn through the flame several times, after 
which they are ready for staining. Abel recommends that after 
covering the dry specimen with a watery concentrated methyl- 
ene-blue solution (Unna) it shall be heated until it steams, 
washed in water, dried with filter-paper and mounted in Canada 
balsam. By this process the gonococci as well as the other cocci 
are stained a deep blue. 

The gonococci are easily recognized as they lie in pairs next 
to each other (biscuit-shaped), and are mostly found in small 
groups both within and without the protoplasm of pus cells. 
When they are found outside these cells, they might readily be 
mistaken for other cocci if we had no method of differentiation. 
This is found in the decolorizing procedure of Gram, by the use of 
Lugol's solution. The gonococci are decolorized, while the other 



PELVIC EXAMINATION, 



61 



cocci retain the stain. By Gram's method the gonococci may be 
differently stained. The dry sHde specimen, after being stained 
with picrocarmin or thin fnchsin solution, is washed in water and 
dried, then stained for one-half minute with Ehrlich's anilin -water 
gentian-violet solution, w^ashed one minute with Lugol's solution 




Fig. 42 a. — Secretion from gonorrheal vaginitis, showing the gonococci both 

within and without the pus cells. 
a, Pus cell containing gonococci; b, pus cell undergoing dissolution; c, large 

epithelial cell. 




Fig. 42 b. — Secretion of simple vaginitis, showing various forms of organisms 

found and preponderance of epithelial cells. 

a, bacilli; b, streptococci; c, staph^dococci; d, pus cell. 

(iodin I , potassium iodid 2, water 300), and moved in alcohol until 
maximum decolorization is secured. After being washed in run- 
ning water, dried, and mounted in xylol-Canada balsam, the gono- 
cocci are found to be stained red, while the other cocci are blue. 



62 



GYNECOLOGY. 



The gonococci are found in sections with much more difficulty 
than in the dried specimens. Wertheim's method consists in 
soaking the sections for three to five minutes in anihn-water 
gentian- violet, in Lugol's solution one minute, in 95 per cent, 
alcohol for decolorizing, — but this should not be complete, as the 
section must retain a distinctly violet color, — in water methyl- 
blue solution for a few minutes, in absolute alcohol one-half to one 
minute, in oil of bergamot and finally mounted in Canada balsam. 
The most difficult part is to determine the time the section should 
be left in the alcohol: if for too short a time, the gonococci are not 
seen upon the too dark background ; if the time is too long, they 
are decolorized. 

As to desirable culture-media for cultivating gonococci, 
Coplin advises urine-agar. The urine is neutralized or rendered 
faintly alkaline. One per cent, of peptone and five -tenths of 
sodium chlorid added. After filtration, preliminary boiling, 
filtration while hot, and again when cold, the agar is added and 
dissolved as in the preparation of beef -peptone agar. In forty- 
eight to seventy-two hours after inoculation, large colonies of 
gonococci will develop in such a fluid. 

91. Staphylococcus pyogenes aureus is the most important 
micro-organism, because the most frequent. (Fig. 43.) It is 





Fig. 43.— Staphylococcus Pyogenes 
Aureus. From Pure Culture in 
Bouillon. (Zeiss, 2 mm., Oc. c.) 



44. — Streptococcus Pyogenes. 
From Culture in Bouillon. 
(Zeiss, 2 mm. Obj., Oc. c.) 



found Upon almost all the cutaneous and mucous surfaces of the 
body, in water and in the air, especially that of hospital wards. 
The organisms difter greatly in virulency, and outside of the body 
have great tenacity of life. It is a spherical coccus, which grows 
readily in clusters or grape-like masses upon all the ordinary 
media, promptly liquefies gelatin and falls to the bottom, pre- 
senting a bright orange color. It stains readily with the anilin 
dyes. The other organisms of this growth are less virulent. 



PELVIC EXAMINATION 



63 



92. Streptococcus pyogenes grows in the form of chains, which 
may be of considerable length. (Fig. 44.) It grows more slowly 
than the staphylococcus and is much less resistant outside the 
body and dies out in culture more readily. As a form of infection 
it is more virulent than the staphylococcus. It is the most fre- 
quent cause of puerperal fever and puerperal peritonitis. It is 
frequently found in pyemia. It can cause inflammation, local 
suppuration in any portion of the genital tract, and may invade 
the lymphatics and blood-vessels and cause peritonitis or septi- 
cemia. 

93. The bacillus coli communis is an organism which grows in 
short, thick rods with rounded ends, and occasionally forms long 
threads. (Fig. 45 . ) It forms no spores. It is the chief organism 
of the large intestine under normal conditions. It is a frequent 
cause of suppurative peritonitis, and is found in suppurative 
conditions associated with intestinal inflammation and suppura- 




Fig. 45. — Bacillus Coli Communis. 
From Pure Culture in Bouillon. 
(Zeiss, 2 mm. Obj.. Oc. c.) 




Fig. 46. — Bacillus Tuberculosis. 
(Zeiss, 2 mm., Oc. c.) 



tion. It is frequently present in inflammation of the urinary 
tract, such as cystitis, pyelitis, and renal abscess. Cultivations 
are frequently more virulent. These organisms may be respon- 
sible for inflammation or even suppuration of an ovarian cyst 
following twisting of the pedicle. 

94. The bacillus tuberculosis occurs as minute rods which 
measure 2.5 /Jt to 3.5 /j. in length and 0.3 /-/ in thickness. (Fig. 46.) 
They are slightly curved, fairly uniform in thickness, but slightly 
swollen at the ends. They retain their vitality for a considerable 
period outside the body, also resist drying and putrefaction, but 
readily succumb Avhen exposed to direct sunlight. All the genital 
structures are susceptible to the tubercular infection, but it occurs 
most frequently in the Fallopian tubes. When found, careful 



64 GYNECOLOGY. 

examination should be made to exclude its presence in other 
portions of the body. Tubercular peritonitis may occur at any 
age, but is most frequent between twenty and thirty years. The 
urinary tract is not infrequently involved. When the bladder 
is the seat, it produces a very distressing cystitis. It may be 
primary or secondary; when the latter, it may have descended 
from the kidney. The writer has recently seen a girl, fifteen 
years of age, whose parents died of pulmonary tuberculosis, in 
whom the entire bladder mucosa was involved. Both ureters 
were distinctly palpable through the vagina and could be outlined 
as thickened, indurated cords. 

The tubercle bacillus, like the gonococcus, may be studied in 
the secretions or in sections of the infected tissues. 

The staining is best managed by Gabbett's quick-staining 
method, in which the dry specimen is stained ten minutes in 
carbol-fuchsin (fuchsin, i.o; alcohol, lo.o; acid, carbolic, 5.0; aq. 
dest., 1 00.0), washed in water, dried with filter-paper, placed for 
five minutes in sulphuric -acid-methyl-blue solution (methyl -blue, 
2.0; acid, sulph., 25.0; aq. dest., 100. o), again washed in water and 
dried with filter-paper. If red areas still remain, the specimen 
must be replaced for several minutes in the sulphuric-acid- 
methyl-blue solution. After drying, the specimefi should have 
a light blue appearance; then it should be mounted in Canada 
balsam. The tubercle bacilli are stained red, while everything 
else is stained blue. Sections for staining are placed in either 
warm or cold carbol-fuchsin solution for twenty-four hours. 
After treatment with sulphuric -acid-methyl-blue solution, the 
section is dehydrated in alcohol, cleared in xylol, and mounted 
in Canada balsam. 

95. Exploration of the Urethra, Bladder, and Ureters. — A 
digital exploration of the bladder is rarely required. Frequent 

and painful micturition may re- 
quire a urethral or vesical inves- 
tigation. Inflammation of the 
urethra may be recognized by 
tenderness and thickening of the 
canal as revealed by touch of 
the anterior vaginal wall. The 
urethra can be felt as a cord-like 

Fig. 47.— Skene's Urethroscope. projection beneath the pubcs. 

The condition of the urethral 
mucous membrane can be determined by the use of Skene's 
urethral endoscope. (Fig. 47.) Points of inflammatory red- 
ness, desquamated epithelium, fissures, and thickened membrane 
are thus recognized. It is important that the instrument should 
not be very large, otherwise the pressure obscures the pathologic 




PELVIC EXAMINATION. 



65 



alterations. Dilatation of the urethra by bougies will permit 
the exploration of the bladder by the introduction of a test-tube 
and the use of a small mirror passed into the tube at such an 
angle as to afford a view of a large part of the surface. The 
urethral specula devised 
by Kelly (Fig. 48) afford 
an opportunity to evac- 
uate the bladder and 



give a view of its entire 
internal surface. The 
urethra is dilated by 
bougies to an extent 
sufficient to admit the 
speculum desired, which 
is introduced upon an 
obturator. With a good 

light the condition of the mucous membrane can be recognized 
and suitable medication applied. The best exposure of the sur- 
faces of the bladder is obtained through the electric cysto- 
scope. It is so arranged that the mucous membrane can be 
examined with the bladder either collapsed or in a state of dis- 




Fig. 48. — Kelly's Specula (Urethra). 



V 



Figs. 49 and 



-Ureteral Catheters. Metal and Soft. 



tention. AVith it the orifices of the ureters can be exposed and 
catheterized, thus facilitating the determination of the relative 
condition of the two kidneys. The catheter can be passed with- 
out the speculum or cystoscope, but the danger of introducing 
infectious material from the urethra or bladder is too great to 





Mouse-tooth Forceps for Cotton Pledgets. 



render it an advisable procedure. A long ureteral catheter of 
soft material can be introduced to the pelvis of the kidney. It 
affords certain knowledge of the condition of the organs as deter- 
mined by their secretion. This knowledge mav be of infinite 

5 



66 



GYNECOLOGY. 




Fig. 52. — Kelly's Evacuator. 



value when we determine that one kidney has been destroyed. 
Its use also discloses the existence of stricture or obliteration 
of the ureter. A flexible bougie with wax tip has been employed 

by Kelly and others in the 
diagnosis of a calculus in the 
pelvis of the kidney or in the 
course of the ureter. 

Harris's seggregator or 
separator is an apparatus 
which consists of a double 
catheter, the ends of which 
are separated after being in- 
serted into the bladder by 
pushing the vesicovaginal 
septum between them from 
the vagina with a blunt staff 
introduced into the latter canal. Sulci are thus formed in which 
the urine of each kidney accumulates separately and is drawn off 
into separate receptacles. This apparatus permits the secretion 
of each kidney to be studied at a less expenditure of skill than 
is required for catheterization of the ureters. 

Palpation of the 
ureter, by which 
thickening and in- 
flammation of the 
canal can be deter- 
mined, is practised 
by passing the finger 
behind the uterus in 
the vagina, and then 
drawing it forward 
upon either side of 
the cervix (Sanger). 
The ureter will slip 
over the finger, giv- 
ing the sensation of 
a good-sized cord. 
In inflammation, the 
ureter will be thick- 
ened, and the patient 

will complain of pain. In a case under my observation blood 
and urine were ejected with force from the urethra when pressure 
was made over the right ureter. 




Fie 



53. — Harris' Double Catheter for Obtaining 
Urine from Kidneys Separately. 



ABDOMINAL EXAMINATION. 



67 



96. 



ABDOMINAL EXAMINATION. 

Preliminaries. — The appearance of the patient and her 



subjective symptoms will indicate the necessity for an examina- 
tion of the abdomen. The patient must have her clothing so 
adjusted that the entire surface of the abdomen can be exposed. 
She should lie in the dorsal position, upon an examining chair, 
bed, or table, with her limbs slightly flexed. A sheet is thrown 
over her lower extremities and drawn over the symphysis, when 
the clothing is raised and her abdomen exposed. 




Fisf. 



54- 



-Abdomen Prepared for Examination. 



97. Inspection. — An investigation of the external surface of 
the abdomen is of great value. The linea nigra, linea striata, and 
increase of pigment about the umbilicus and lower abdomen are 
signs indicative of a previous or present pregnancy. These dis- 
colorations having once occurred are never eft'aced, and are conse- 
quenth^ of significance only during a first pregnancy. The linea 
striata are red or purple, when recent ; white and glistening, when 
old. They are caused by overstretching of the skin, hence may 
result from any abdominal enlargement. Discolorations from 
blisters and counterirritants or scars from leech bites and wet cups 



68 GYNECOLOGY. 

are indications of previous inflammation. The superficial abdo- 
minal veins are enlarged by any pressure upon the deeper vessels, 
and the enlargement occurs in pregnancy, in fibroid, ovarian and 
other large tumors. The subcutaneous tissues become edema- 
tous in general dropsy and from acute abdominal inflammation. 

The abdominal enlargement is symmetric, irregular, or nodu- 
lar; the abdomen is flattened and broadened in ascites, narrowed 
and projecting in pregnancy, myomata, and ovarian cysts. The 
tumor is spheric, most prominent above to the right in pregnancy, 
rises abruptly, attaining the greatest prominence near the um- 
bilicus in ovarian cystomata, and is less likely to be symmetric 
in myomata. The surface of the skin is smooth and glistening 
from internal enlargement, and hangs in folds over the symphysis 
in obesity. A very dependent mass may be due to the protrusion 
of a large tumor between the separated recti muscles, or to a des- 
moid tumor of the abdominal walls. A large projection from the 
median line may be caused by a ventral hernia. Frequently the 
movements and outlines of the intestinal coils may be recognized. 
Fetal m.ovements, contraction of muscles, and peristaltic action 
of the intestines can often be seen. Enlargements in the upper 
abdomen are due to growths in the liver, distention of the gall- 
bladder, enlargement of the kidney, or malignant disease of the 
ascending or transverse colon. In the median line the liver, 
stomach, pancreas, or transverse colon may be the seat of origin. 
Above, upon the left side, it may be the spleen, the left lobe of 
the liver, the cardiac end of the stomach, or the left kidney; and 
below, the descending colon. In the lower abdomen the genital 
organs afford the majority of abnormal growths. A tumor in the 
right inguinal region should always awaken a suspicion of appen- 
diceal inflammation or malignant disease of the colon. 

98. Palpation. — Palpation may be practised during the exer- 
cise of the preceding step. It consists in placing the hands, pre- 
viously warmed, upon the bare abdomen, and gently moving 
them from side to side, now close together, or again bringing the 
entire abdomen between their grasp. The tips of the fingers or 
the entire hand may be applied. Palpation enables us to recog- 
nize the presence of an abnormal growth ; its situation, mobility, 
density, and relation to the abdominal viscera. Its dimensions, 
smoothness, or irregularity are recognized by carefully outlining 
the tumor. The relations and mobility of the growth are deter- 
mined by changing the position of the patient. 

The patient generally should be placed upon her back, with 
the limbs flexed and the head and shoulders slightly elevated. 
The confidence and cooperation of the patient must be obtained 
in order to secure relaxation of the muscles. It is necessary to 
proceed with the utmost consideration and gentleness, as rough, 



ABDOMINAL EXAMINATION. 69 

hasty, and inconsiderate palpation causes muscular rigidity and 
defeats the object. Pelvic abnormalities may require vaginal 
touch in conjunction Avith palpation, which has already been 
discussed under the bimanual examination. (Section 62.) 

99. Difficulties. — Information may be rendered difficult to 
secure by palpation because of a large deposit of fat in the 
abdominal Avails or rigidity of the muscles from fear or actual 
tenderness. The patient may in general be so reassured as to 
permit the investigation to be satisfactorily completed. In 
inflammatory collections it is often necessary to exercise care in 
the procedure to avoid rupture of the mass and the escape of its 
contents into the peritoneal cavity. 

100. Percussion, though described separately, may be prac- 
tised in conjunction with the two preceding steps. It consists in 
eliciting resonance or dulness by mediate or immediate percus- 
sion. Fluctuation is recognized by placing a hand upon one side 
and striking upon the abdomen, more or less remotely, with the 
finger-tips of the other. A long Avave indicates that the fluid is 
free or contained in a large sac. A short or indistinct wave is 
produced by fluid contained in a sac AAdth numerous partitions or 
septa. The chief value of percussion is in determining solid or 
fluid tumors from distentions of the abdomen by gas or ascites. 

The ability to elicit resonance and dulness is utilized in the 
diagnosis between free fluid Avithin the abdomen and that con- 
tained within a cyst. In the former a zone of resonance is 
elicited over the summit of the distention, AA'hile the remainder 
of the surface Avill be dull. The zone of resonance changes AA^th 
the position of the patient, Avhile in a cyst there is dulness OA'cr 
its surface and resonance aboA^e, and generally upon one side. 
In the latter the relative outline of the zones of resonance and 
dulness do not A^ary with change of position. The solid or cystic 
tumor, as it increases in size, pushes the A'iscera upAA^ard and to 
the opposite side; hence the situation of the zone of resonance. 
Resonance at the summit of the SAvelling in ascites is due to gas 
in the intestines, floating them to the surface. Should the 
mesentery be too short, from inflammation or great abdominal 
distention, to reach the surface, percussion giA^es dulness; AA'hile 
deeper pressure displaces the inter A^ening layer of fluid, and again 
affords resonance. In localized peritoneal accumulations percus- 
sion aids only in defining their boundaries, and presents the sen- 
sation of fluctuation. 

loi. Auscultation is practised directly by placing the ear OA^er 
the abdomen, Avith a toAvel or sheet interA^ening ; and, indirectly, 
through the medium of a stethoscope. The former enables the 
physician rapidly to find the sound, the latter to study it 
minutely. Auscultation is of limited application. It enables us 



70 GYNECOLOGY. 

to hear the fetal heart-sounds, the bruit produced by the rush of 
blood through the uterine sinuses, and various sounds induced by 
gas and liquids in the intestines. The fetal heart-sounds are 
characteristic of pregnancy ; the bruit is heard in pregnancy and 
fibroid tumors alike. Efforts have been made to diagnose the 
seat of intestinal obstruction by the gurgling noise in the intes- 
tines, but our knoAvledge of the normal sounds is not sufficiently 
definite to enable us to make it of much value. 

102. Exploratory Puncture. — Exploratory operations for the 
purpose of diagnosis may be one of two classes: puncture and 
incision. Puncture is divided into two procedures : tapping and 
aspiration. The former is applicable to the diagnosis and treat- 
ment of ascites ; the latter, where it is desirable to lessen the size 
or to determine the contents of a cyst. 

103. Tapping, or paracentesis abdominis, was at one time the 
only method of treating abdominal collections of fluid, whether 
free or confined within a cyst. The instruments used should 
consist of a trocar and cannula, about \ of an inch in diameter, to 
which a rubber tube may be attached. If Well's blunt cannula 
is used, a bistoury must be employed to make the incision. The 




Fig. 55- — Nest of Trocars. 

patient is placed upon her side near the edge of the bed ; a point 
is selected in the median line, about midway between umbilicus 
and symphysis, which percussion has demonstrated to be free 
from intestine ; and the surface is frozen by the application of ice 
and salt or a spray of ethyl chlorid. An incision is made through 
the skin, and the trocar is plunged, by a quick, rotating thrust, 
into the peritoneal cavity. The finger is held upon the instru- 
ment to govern the distance it is to be introduced. The trocar is 
withdrawn and a rubber tube is applied to the cannula to convey 
the fluid into a receptacle. The complete evacuation of the fluid 
is secured by pressing upon the abdomen toward the cannula. 
Arrest of the flow by the intestines floating against the end of 
the cannula can be obviated by changing its position. As the 
contents are evacuated the entrance of air into the abdomen may 
be prevented by keeping the end of the rubber tube submerged. 
The cannula is withdrawn and a piece of aseptic gauze is placed 
over the opening and held by a small strip of plaster. The 
withdrawal of a large quantity of liquid is frequently followed by 
symptoms of syncope. The patient should be kept in the 



ABDOMINAL EXAMINATION. 



71 



horizontal position, and, if necessary, given whisky or brandy 
(f5J, per Oram), spt. ammon. aromat. foj, well diluted, strychnin 
sulphate (gr. -^^ to 3^^) , atropin sulphate (gr. xio" ) ' hypodermically, 
or inhalations of a few drops of amyl nitrite. 

104. Aspiration should be the procedure chosen when it is 
desired to evacuate the contents of a cyst. The use of the trocar 
favors the entrance of air and of pathogenic germs, and its open- 
ing permits the escape of the cyst-contents into the peritoneal 
cavity, which not infrequently favor the development of perito- 
nitis. The contents of a cyst should consequently be entirely 
removed if the wall has been perforated. The use of the hy- 
podermic syringe for the withdrawal of a small quantity of fluid 
for examination is reprehensible. The patient encounters a 
greater risk from the escape of a portion of the contents of a 
tense cyst through even a small opening than can be compen- 
sated by any advantage derived 
through an examination of the fluid. 
For aspiration two instruments may 
be used, one of which will hold a few 
ounces, in which the needle is con- 
nected with the reservoir ; the other, 
used in large accumulations, consists 
of a large air-pump connected b}^ 
tubing with a needle, a quart bottle 
intervening (Fig. 56). Rapid suc- 
tion exhausts the air in the bottle 
and causes the fluid to run until the 
cyst is emptied or the bottle filled. 
Strong suction when the cyst is 
nearly empty draws its sides into the 
needle and stops the flow. The with- 
drawal of the contents of the cyst is an advisable procedure when 
the pressure of the tumor is so great as to obstruct the circulation 
and lead to dyspnea, decreased renal secretion, and more or less 
anasarca. The operation in such cases, by facilitating restoration 
of secretion, promotes a favorable result in subsequent removal 
of the cyst. The procedure may be necessary, also, to prolong 
the life of the patient until a skilled operator can be secured. 
Broad ligament cysts are occasionally cured by aspiration. It 
affords an opportunity to clear up the diagnosis in otherwise 
obscure cases. Tavo conditions particularly can be determined 
by microscopic examination of the fluids. Hydatid disease is 
recognized by finding even a single hooklet. Malignant disease 
is determined by finding the presence of blood-corpuscles or 
particles of malignant tissue. The blood is mixed with the fluid. 
To examine it, the fluid should be drawn into a clean vessel, 




Fig. 56. — Aspirator. 



72 GYNECOLOGY. 

covered, and permitted to stand for twelve hours, when the 
blood-corpuscles will be found at the bottom or adherent to the 
sides of the vessel. Tapping and aspiration should always be 
done through the abdominal walls, never through the vagina or 
rectum, on account of the more difficult antisepsis and consequent 
greater danger of infection. 

105. Exploratory incision in cases of difficult or doubtful 
diagnosis is a most effective method for making known the con- 
dition, but should be very infrequently practised. The more 
carefully the sense of touch is cultivated, the less frequently will 
an incision be required. The position of a patient who has 
nerved herself to undergo an abdominal operation, only to ascer- 
tain that her trial and suffering have been without avail, is m.ost 
distressing, and is not calculated to lead the surgeon frequently 
to repeat it in cases of extremely doubtful character. 



THERAPEUTICS. 

106. Classification. — Gynecologic therapeutics may be divided 
into general and local, medical and surgical, and the time will 
not be misemployed if we consider the subject from the stand- 
point of preventive and curative. 

107. Extension. — A cursory consideration renders it evident 
that the capable gynecologist must be versed in medicine, and 
must be able to distinguish genital affections from disturbances 
of other organs and to recognize the indications and contrain- 
dications for special methods of procedure. 

108. Infection. — We need but to review the consideration of 
micro-organisms set forth under diagnosis to appreciate the im- 
portance of combating infection in its various manifestations. 
Not infrequently deaths following operations are attributed to 
heart failure, shock, pyelonephrosis, and pneumonia, when they 
are without question due to infection. Infection is more likely 
to reach a wound from unclean hands or instruments rather than 
through the atmosphere. 

109. Terms. — The study of such conditions has originated 
the terms sepsis, antisepsis, and asepsis. Sepsis, of course, in- 
dicates the existence or sequela of infection; antisepsis, the use 
of agents which are either destructive to bacteria or hinder their 
baneful influence. Asepsis comprises the exercise of such means 
as shall exclude from the field of operation all pathogenic germs 
and their products. The latter is the ideal procedure, but when 
we have to deal with agents so intangible that it requires a micro- 
scope to discover their presence, and when it is absolutely im- 
possible to preserve aseptic or sterile everything that may come 



THERAPEUTICS. 



73 



in contact with the affected tissues, a combination of the two 
methods seems the w4ser plan of procedure. 

Sterilization means the entire destruction or removal of 
germs. Complete sterilization of everything is an ideal asepsis. 

no. Sterilization Methods. — The most effective agent for 
sterilization is the flame, but this can rarely be used because of 
its destructive influence upon the temper of instruments. It is 
employed to destroy worthless and dangerous objects, such as 
soiled dressings. 

Heat ma}^ be employed in the dry and moist forms. The 
vegetative bacteria are destroyed by comparatively low tem- 
peratures, from io6° F. to 150° F. The spore -bearing bacilli 
require a higher tempera- 
ture and stronger chemical 
solutions. 

Sterilization by dry heat 
is infrequently employed, 
for the reason that a tem- 
perature of 284° F. for 
three hours is required to 
insure the destruction of 
the spore-producing micro- 
organisms (Robb). It is 
rendered unavailable, not 
only by the time required, 
but it is injurious to instru- 
ments and destructive to 
ligatures and dressings. 

An effective and easy 
method of sterilization is 
by the use of steam, which 
requires an apparatus from 
which the air can be ex- 
pelled and the temperature 
maintained evenly at 212° 
F. A convenient and cheap apparatus for this purpose is an 
Arnold's copper sterilizer (Fig. 57). Ligatures and sutures may 
also be sterilized in the same way, but much more effectively by 
boiling. Silk will not stand long or repeated boiling without be- 
coming friable. The towels, sheets, and operating gowns should 
be subjected to what is called the fractional method. This con- 
sists in placing the material in the sterilizer for one hour the first, 
and one half hour each succeeding day for two days. They should 
be carefully protected until used. When dry and properly pro- 
tected, they will remain aseptic for an indefinite time. 

III. Sterilization of Instruments. — The instruments for ex- 




Fig. 57. — Arnold Steam Sterilizer. 



74 



GYNECOLOGY. 



amination and operation should be capable of being thoroughly 
cleaned, and after every operation should be cleansed in hot 
water and boiled before the next operation. They should be 
placed in trays dry, or upon a sterile table. It was formerly the 
custom to place instruments in a five per 
cent, solution of carbolic acid. If the instru- 
ments are properly cleansed, the use of this 
agent is unnecessary, and in many operative 
procedures, particularly those upon the peri- 
toneal cavity, it is objectionable, in that it 
causes irritation of the delicate structure of 
the peritoneum. The instruments should 
be sterilized before beginning an operation. 
Davidson says five minutes' boiling in water 
destroys all germs, but if the instruments 
have been used in pus or about gangrenous 
cases it is important that we should exercise 
still further precautions to render them abso- 
lutely sterile. They may be boiled for half 
an hour in a five per cent, solution of car- 
bohc acid. The water should be boiling be- 
fore the instruments are placed within it, or 
The latter can be avoided by using a one 
of carbonate of soda. This method of pro- 




Fig. 58. — Steam-pres- 
sure Sterilizer. 



else they will rust. 
per cent, solution 

cedure affords a ready means of sterilizing an instrument which 
has been dropped during an operation. It has the advantage 
that any vessel can be used. The instrument trays — preferably 
of glass or porcelain, as be- 
ing most readily disinfected 
— should be sterilized by 
heat, or, after careful wash- 
ing with soap and hot 
water, should be filled to 
the brim with i : 500 solu- 
tion of bichlorid. Trays 
should be emptied and 
washed out with plain ster- 
ilized water before the in- 
struments are placed in 
them. 

112. Sponges. — Sponges 
require more care and at- 
tention than any other part of the operation. I formerly used 
gauze pads made by taking a yard of gauze and folding it six or 
eight times, so that it made a pad from six to eight inches square. 
All selvage edges were turned in and whipped over by continuous 




Fi.^ 



59- 



-Sterilizer for Boiling Instruments. 



THERAPEUTICS. /O 

suture. These pads were boiled for half an hour, dried, and kept 
in sterile vessels ready for use. They were again boiled im- 
mediately before the operation. They were inexpensive, and, 
therefore, could be thrown away after each operation. The 
majority of operators now use dry gauze for sponges; pieces of 
gauze a yard in length are so folded that the raw edges are not 
exposed. They are done up in packages or placed in a metal 
receptacle so arranged that steam will pass through them, and 
are subjected to sterilization by the fractional method. They 
should be kept protected from dampness or any possible source 
of infection until used. The person who dispenses them at the 
operation should only handle them with a sterilized metal in- 
strument. The greatest care must be exercised to make certain 
that all pieces of gauze are accounted for before closing the 
abdominal cavity. When the operator is to depend upon un- 
certain assistants, it is better to return to the smaller pieces of 
gauze, which can be washed and used over and over during the 
operation. When the operator pre- 
fers sponges, a good, fine, tough ^_^._._--^^-^ 
Turkish sponge should be chosen, ^__l_ • ■ 
using a definite number each of !| 

round and flat sponges. They ;;; | — 

should be carefully cleansed by ; f 
being placed in a towel or bag and ' ' 
pounded with a cane until as much 
as possible of the dust and sand is _ -g i.;,,^^^_,__,_.,.__,_^^^^__.^___ 
removed. Then they are placed I, 

in water acidulated with muriatic ^^§^- ^o -Gauze Pads, 

acid sufficient to give a strong acid 

taste, in which they remain for twelve hours. This dissolves out 
the sand and earth. The sponges are then washed in green soap 
through a number of waters until they become perfectly clean, 
after which they are placed in a five per cent, solution of carbolic 
acid. A good plan of procedure in cleansing sponges is to 
place them in a solution of hyposulphite of soda — a pound of the 
salt to a gallon of water for each dozen sponges. Add to this an 
ounce of muriatic acid or half a pound of oxalic acid. The addition 
of the acid to the soda results in a double decomposition, in which 
sulphurous acid and sulphur are set free. The acid burns out 
the organic material in the sponge and at the same time bleaches 
it. Sponges should not be permitted to remain in this solution 
longer than from five to ten minutes. They are then washed 
in water until there is no longer any whitening of the water with 
the sulphur. They may then be placed in a five per cent, solu- 
tion of carbolic acid. When the sponges have been used, they 
may be w^ashed and used again, unless they have been soiled by 




76 GYNECOLOGY. 

contact with some special poison or infectious material, when 
they should be thrown away. In recleansing the sponges they 
should first be washed in cold water to remove the blood, then 
soaked in a solution of washing soda, half a pound to the gallon, 
and afterward in a solution of hyposulphite of soda and oxalic 
acid. The solution in which the sponges are kept should be 
changed every two or three weeks. 

113. Ligature and Suture Material. — Methods for Its Pre- 
paration and Preservation. — The material used by the majority of 
operators is silk. Pozzi recommends that it shall be boiled with 
carbolic acid, 50: 1000, wound upon glass reels, and kept in this 
solution, which should be changed every week. Not too large a 
quantity should be prepared at a time, as the nearer to the opera- 
tion, the less irritating it is. Hegar uses iodoform silk which is 
immersed twenty-four hours in iodoform 20 grams, ether 200 
grams. This is dried, wound upon bottles, and kept in glass 
boxes. Silk may also be boiled in a sublimate solution (i : 1000). 
Nilson recommends that suture material for superficial stitches 
should be boiled in wax and carbolic acid, as it is thus less likely 
to become infected. Apropos of this method, I used a suture of 
this kind in closing the lacerated perineum of a patient immedi- 
ately following labor. Sutures were removed a week later. Two 
years subsequently, during examination of this patient I noticed 
a dark speck or groove upon the perineum, and on closer in- 
spection found it to be a ligature that had not been removed. 
It was raised up, cut, and withdrawn, when it was found that it 
occupied a groove, which was completely cicatrized and ap- 
parently was not irritated. The possibility of infection of silk 
when used upon the stump of a suppurating tube, or in a pelvic 
cavity when suppuration is present, and the long-continued sinus 
that results until the ligature itself has discharged, have led me 
to prefer some material for ligation that is more certain to be 
absorbed and will not remain in the tissues so long. I have had 
occasion to open a sinus and remove a large ligature from a 
patient upon whom the operation had been done four years be- 
fore, and the abscess did not form for three and one-half years. 
Consequently, for some time I have used nothing but catgut for 
ligatures and internal sutures. This material, when carefully 
prepared, is perfectly safe, and we have no reason to feel that the 
patient will experience inconvenience after convalescence occurs. 
Patients in whom no suppuration has occurred, nor sinus resulted, 
have subsequently suffered from pressure upon the nerve-fibers 
by an encysted ligature, requiring reoperation a year or more 
later for removal of the ligature in order to secure relief. Catgut 
for ligature is prepared as follows: No. 00, No. o, and No. 2 cat- 
gut, as obtained from the shops in long pieces, is placed in ether 



THERAPEUTICS. 77 

or benzin for a number of days, or even weeks, to extract the fat. 
It is removed from this and tightly wrapped upon wooden blocks 
or glass tumblers, and placed for thirty hours in a solution of 
bichromate of potash: 

R . Potasii bichromat 1.5 

Acid, carbolic, ) -_ ^ 

^1 ■ > aa 10. o 

Glycerin., I 

Aqua, 480.0 

The bichromate is dissolved in the water, and the carbolic acid 
and glycerin are added. 

The previous fixing of the gut before its immersion in the 
solution is very important, as it otherwise becomes hopelessly 
twisted and entangled. After removal from the solution the 
strands should be wrapped upon previously prepared boards 
about a meter long, and while so wrapped it should be carefully 
dried. From these boards it is cut in meter lengths, and the 
pieces are tightly wrapped upon glass drainage-tubes. Each 
tube contains two pieces of gut. These tubes are placed in a 
i: 1000 solution of sublimate in water for eight hours. This 
solution is poured off and replaced by a i : 500 solution of sub- 
limate in alcohol (90 per cent.), in which the catgut remains 
for twenty-four hours. From this solution the tubes are lifted 
by sterile forceps into absolute alcohol, to each half pint of which 
one dram of sterile glycerin has been added. The tubes are 
removed from this solution for use. Any unused catgut after 
an operation is not replaced. 

The No. 2 gut is employed for ligatures, the No. 00 and No. o 
for sutures. Gut so prepared is, in my experience, unirritating 
and a satisfactory material for ligatures and sutures. 

When it is not desired to harden the catgut or there is no 
need for its remaining in the tissues for such a length of time, 
the solution of bichromate of potash may be omitted. Boeckman 
suggests the following method of rendering the catgut safe for 
use. The gut, after being cleansed in ether, hardened if desired, 
and thoroughly dried, is cut into desirable lengths, wrapped in 
wax paper, sealed in small envelopes, and subjected to a tem- 
perature of a little above 284° F. for four hours. Pus-forming 
germs are destroyed at lower temperatures, but spore -bearing 
germs, as anthrax, so common in the intestine of the sheep, are 
killed only at the higher temperature. The envelopes remain 
unbroken until the catgut is desired for use. Silkworm-gut 
forms an excellent suture, is clean, not readily infected, and 
is easily taken care of. It may be boiled for ten minutes prior 
to the operation. 

114. Dressings. — Gauze medicated with various germicidal 
or inhibitory agents has been advocated, but it does not present 



78 GYNECOLOGY. 

any advantages over the sterilized gauze. The latter is non- 
irritating, and serves every purpose. It should be sterilized by 
subjecting it to steam. The fractional method, of course, being 
employed. It should be subjected one hour the first day, the 
second day half an hour, and the third day the same length of 
time, then dried in a hot oven and placed in a closed vessel, and 
kept carefully wrapped until it is used. 

115. Operator and Assistants. — Personal cleanliness should 
be a matter of conscience. A person with nasal catarrh or bad 
breath from decayed teeth or foul stomach is disqualified to be 
either an operator or assistant. This is particularly true in 
peritoneal operations. Even the slightest examination should 
not be undertaken unless the hands and nails are carefully 
cleansed, in order to insure against the introduction of infectious 
material, and in every operative procedure the hands and arms 
should be scrubbed with soap and hot water, giving thorough 
attention to the condition of the nails. The longer the hands are 
scrubbed with soap and water, the less active are the germs that 
inhabit the surface beneath the finger-nails. After thorough 
washing with soap and hot water, the nails should be scraped and 
the washing again repeated. The fingers, and especially about 
the nails, should be scrubbed with a piece of sterile gauze wet 
with a 1 : 500 solution of bichlorid in 70 per cent, of alcohol, and 
subsequently washed in sterile water. Nurses and assistants 
who are to take part in the operation and handle sponges or 
dressings should be required to rigidly exercise the same pre- 
cautions, and should be taught the importance of carefully 
avoiding contact with any nondisinfected article; and if they 
should accidentally touch a door, basin, clothing, the face, or any 
nonsterile object, they should again scrupulously cleanse their 
hands before coming in contact with dressings or instruments. 
Kelly advocates, subsequent to scrubbing the hands in soap and 
hot water, that they should be placed in a solution of perman- 
ganate of potash (4 : 1000), and this stain removed by washing 
in a concentrated solution of oxalic acid, then in lime-water, and 
finally in sterile water. From considerable experience I have 
been led to think well of the method suggested by Furbringer, who 
first washes with soap and hot water, then with bichlorid (pref- 
erably the acid solution), following with alcohol at 90 per cent. 
Probably the most effective method of cleansing the hands is 
to wash them with equal parts of sodium carbonate and calcium 
chlorid to which water is gradually added. The chlorin set free 
is the effective agent. There are but few persons, however, 
whose hands will endure the employment of this method of 
cleansing several times daily. Before examining a case of 
cancer where there is considerable decomposing material, it is 



THERAPEUTICS. 79 

well to anoint the fingers with turpentine, and then with vaselin, 
as in this way the disagreeable odor is more readily removed 
from the fingers. It would be wise for the operator to wear 
rubber gloves, or draw a condom over two fingers before ex- 
amining cases of cancer or other infectious cases. A surgeon 
engaged in a general surgical practice would do wisely to wear 
rubber gloves when operating within the peritoneal cavity. 
Gloves should always be worn when the operator has recently 
examined or operated upon patients Avho were suffering from 
some infectious disease. 

1 1 6. Precautions. — During the progress of an operation the 
operator should have, conveniently situated, two vessels, one 
containing a solution of i : looo acid sublimate, and the second 
sterile water, into which he can occasionally dip his hands. 
In operations within the abdomen it is better that the bichlorid 
should be removed by sterile water. He should w^ear clean linen 
and should have his clothing entirely covered by a sterilized 
apron. When there is much fluid, as in plastic operations on the 
vagina, in which continued irrigation is practised, the clothing 
should be covered with some waterproof material beneath the 
apron. 

117. Room and Environment. — The room and surroundings 
of the patient should receive careful consideration. The room 
should be well lighted and ventilated, and thoroughly cleaned; 
be free from matting, hangings, and everything that is likely to 
retain dust ; in fact, no more furniture should remain in the room 
than is absolutely necessary. The operating room should be one 
whose walls can be thoroughly washed and carefully cleansed; 
the furniture should consist of metal and glass. When the opera- 
tion is to be performed in a dwelling, the room should be carefully 
scrubbed with a carbolic acid solution (50: 1000) two days in 
advance. In a private house where the rooms are old or their 
condition at all suspicious, they should be disinfected with a 
formaldehyd apparatus. It was formerly the practice to operate 
under the carbolic acid spray, but it was found to have a pre- 
judicial influence upon the peritoneum. Until quite recently 
some operators still kept a spray in the room for the moisture 
and to secure the beneficial influence of the carbolic acid, but 
the drug is so disagreeable and injurious to many patients that 
the practice has been discontinued. Sterilized water should be 
at hand in carefully covered vessels, and when antiseptic solu- 
tions are used, they should be designated so that no mistake can 
be made. 

118. Examination and Preparation of Patient. — An examina- 
tion should be made of the urine, as to its specific gravity, 
quantity of urea, presence or absence of albumin or sugar, 



80 GYNECOLOGY. 

approximate quantity of solids, and where the conditions in- 
dicate it, the microscope should be employed. A fair estimate 
of the amount of solids may be obtained by Maine's modification 
of Haeser's method, viz. : " Multiply the last two. figures of the 
specific gravity by the number of ounces of urine passed in 
twenty-four hours, and this product by one and one -tenth." 
This estimate includes urea and all other solids. The quantity 
will depend upon the avoirdupois of the patient. Etheridge 
has prepared the following table: 



Weight. 


Urinary 


Solids. 


Weight. 


Urinary Solids, 


90 pounds 

TOO 

no 


789 grains 

854 " 

916 


140 pounds 

150 

160 " 


1078 grains 
1150 
1198 " 


120 " 
130 " 


974 
1028 


- 


170 
180 


1237 " 
1260 " 



The performance of the respective functions of the heart and 
lungs should be investigated. Frequently an examination of 
the blood will be of service. While a low percentage of hemo- 
globin does not preclude operation (as I have performed a 
hysterectomy upon a patient with recovery in whom the hemo- 
globin was only 20 per cent.), it has, however, an important in- 
fluence upon the healing of wounds and the convalescence of the 
patient. A careful blood examination is valuable, therefore, 
in the prognosis of operative conditions associated with anemia. 
The bowels should be thoroughly evacuated; this is particularly 
important when a plastic operation is to be performed upon the 
rectovaginal septum. The diet should be regulated according 
to the proposed operation. In peritoneal and intestinal opera- 
tions milk and other foods containing much waste should be 
excluded. 

A thorough evacuation of the bowels should be secured by 
the administration of half an ounce of Rochelle or Epsom salts, 
or two drams compound licorice powder, or half a bottle of 
magnesium citrate two nights previous to and the morning 
preceding the day set for the operation. A large rectal enema 
of soapsuds should be given the preceding night. The patient 
should be kept in bed for twenty-four hours prior to a serious 
operation. She should be given a general bath twice daily for 
two days, with special attention to washing the external genitals, 
the anus, and the depression of the umbilicus. Vaginal ir- 
rigation with 1 : 2000 sublimate solution should accompany each 
bath. The abdomen and genitalia should be shaved the evening 
before the operation and the abdomen should be washed with 
tincture of green soap and hot water, the flesh-brush being 
diligently applied. If the patient is uncleanly or the skin is oily, 
the surface should be washed with ether, then with soap and 



THERAPEUTICS. 81 

water, and finally with a (i : looo) sublimate solution. This 
washing should be repeated on the morning of the operation, 
and the abdomen should then be covered with a pad saturated 
with sublimate solution, which should be retained by a bandage, 
to be removed when upon the operating table. In all cases it is 
desirable that the field of operation should be again thoroughly 
scrubbed after the administration of an anesthetic, with soap and 
hot water, the superficial soap being removed with alcohol. 

119. Special Preparation. — Vaginal Operation. — The first step 
should consist in a careful cleansing of the vagina. For this 
purpose a combination of creolin with green soap is very effectual, 
using creolin one or two drams, green soap one or two ounces, to 
the quart of hot water. The vaginal canal should be thoroughly 
scrubbed with this solution, introducing two fingers wrapped 
with gauze. This procedure will remove all debris which may 
have lodged in the crypts and folds of the vagina. The solution 
should be removed by washing with sterilized water and then 
with alcohol. Creolin is not so effective an agent in sterilizing 
the vagina as the acid sublimate solution, but it has the advantage 
that it leaves the vagina soft and flexible, which is an important 



Fig. 61. — Irrigating Glass Tube. Open End, 

consideration in obstetrics as well as in all operative procedures 
upon the vagina. The bichlorid and carbolic acid solutions, 
on the other hand, have a constringing effect upon the vagina, 
which renders it less elastic. 

120. Irrigating Tubes. — All the cannula used for the purpose 
of cleansing the vagina should be made of glass (Fig. 6i), as they 
are more readily cleansed, are less likely to contain infectious 
material, and are sufficiently cheap to permit them to be throAvn 
away when used in suspicious cases. If injections are used by 
the patient, there should be no central opening of the nozle, for 
the reason that it may be introduced directly into a patulous 
cervical canal, and fluid thrown with force into the cavity results 
in severe uterine colic. Indeed, fluids have been thrown into 
the uterus and forced by uterine contraction into the tubes, 
which caused serious, if not fatal, pelvic inflammation. There 
is no special advantage in having a curved cannula or tube for 
irrigation. The nozle used by the physician in an operation 
should have but a single orifice, and that should be a central one. 
After irrigation has been practised, pressure should be made 
6 



82 GYNECOLOGY. 

Upon the fourchet, to insure the entire escape of fluid. It is 
sometimes advised that the irrigation should follow the ex- 
amination or operation, but we can not too strongly impress 
upon the student the fact that the genital canal sometimes con- 
tains dangerous germs, and that antisepsis must precede as well as 
follow an operation. In cancer or sloughing fibroids we may, 
in addition to the ordinary disinfection, require the use of de- 
odorizing agents. For this purpose a three to five per cent, 
solution of thymol or two or three tablespoonfuls of Labarraque's 
solution to the quart of water may be used. 

121. Gauze. — After the uterus and vagina are carefully 
cleansed the canal can be packed, if preferred, with iodoform or 
other antiseptic gauze which will remain sweet for a number of 
days. Iodoform is preferable to the simple sterilized gauze. To 
prepare it, ten layers of plain gauze are sterilized by boiling, pref- 
erably in a solution of carbonate of potash, washed, then soaked 
in a solution consisting of iodoform 50, glycerin 100, and ether 
700 parts, after which the gauze is passed through a wringer and 
dried in a darkened isolated room at a temperature of 85° F. 
When dry, it is placed in tin boxes. This gauze should always 
be sterilized before its use. This can best be accomplished by 
heating it to the temperature of 250° F., by which both germs 
and their spores are destroyed. It should be remembered that 
iodoform is not a germicide. Its value is in its reductive in- 
fluence upon the ptomains and leucomains, by which their 
deleterious effects are arrested. Iodoform is poisonous to some 
patients. Sometimes it produces high temperature, irritation 
of the skin, and a smoky, darkened urine, and in others, extreme 
disturbance of the digestive tract. In such idiosyncrasies one 
of the other forms of antiseptic gauze should be preferred. These 
comprise borated, salicylated, carbolized, formalized, and acetan- 
ilid gauze. Sublimated gauze can be made by first boiling it in 
a solution of carbonate of potash (20: 1000), then an hour in a 
(i : 1000) sublimate solution, when it is dried in a sterilizing oven 
and preserved in closed glass jars. Salol and iodol are inferior 
in their action to iodoform. Carbolic acid is unreliable. Aristol, 
an agent that is made by the combination of thymol and iodin, 
is probably preferable to iodoform. It has the advantage of the 
absence of disagreeable odor. The powder is very dry, not 
rapidly soluble, and coats over and protects the surface. 

122. Antisepsis of the cervix and uterine cavity is secured by 
intra-uterine injections of sublimate solution, carbolic acid, 
peroxid of hydrogen, or, preferably, formalin (i : 1000). Of the 
solutions of mercury, the acid sublimate is preferable, for the 
reason that it does not form an albuminate of mercury by com- 
bination with the serum of the blood, and is less likely to be 



THERAPEUTICS. 83 

absorbed and to produce a toxic effect. This agent is not so 
dangerous as in obstetrics, unless there has been a large denuded 
surface. In such cases its use should be followed by an injection 
of sterilized water. In intra -uterine injections a double catheter 
should be employed, in order that the return flow may not be 
obstructed. It may be made of hard rubber, glass, celluloid, or 
metal; the last-named are more likely to be acted upon by the 
mercury salts. If the uterine cavity is well dilated, the double 
tube will be unnecessary. After the cavity is carefully cleansed 
it may be packed with an iodoform gauze tampon, or a pencil of 
iodoform may be introduced. Von Hacker recommends the 
following: Iodoform, 5 drams; gum acacia, glycerin, starch, each 
30 grains; mix, make pencils, introduce into the cavity of the 
uterus. When these pencils give rise to uterine colic, it may be 
preferable to dust the cavity with iodoform through an insufflator, 
or, still better, the use of aristol by the same means. 

In sloughing fibroids or intra-uterine cancer the cavity should 
be irrigated w4th an acid sublimate solution (i : 2000), followed 
either by sterilized water or a solution of chlorid of sodium (6 : 
1000). In operations upon the vagina or cervix continuous 
irrigation may be practised, using for this purpose a solution of 
carbolic acid (5 : 1000), sublimate (i : 2000), formalin (i : 1000), 
or, better, chlorid of sodium (6 : 1000). The irrigation washes 
away the blood, renders unnecessary the use of sponges, and the 
surfaces are constantly kept bathed with the antiseptic fluid. 
It is the preferable procedure in all operations upon the vulva, 
vagina, and cervix. 

123. The Use of Tents. — In dilating the uterus the sponge, 
tupelo, or laminaria tents, although carefully disinfected, are not 
without danger. Pozzi recommends the latter tent, but he first 
immerses it in a saturated solution of carbolic acid and rectified 
spirits, or in a solution of iodoform and ether with a tenth part 
alcohol. ' The objection to the use of tents is the difficulty in 
previously sterilizing the uterine canal. Unless it is thoroughly 
done, as you would in the performance of any operation, the 
patient is in danger of subsequent inflammatory attacks. For 
this reason, in the majority of dilatations, I prefer to use the 
bougies and accomplish rapid dilatation in preference to the 
slower procedure with the tent. 

124. Abdominal Section. — The peritoneum, is a membrane 
exceedingly susceptible to the influence of all chemic agents, and 
its delicate structure would be injured or destroyed by any agent 
of sufficient strength to have a germicidal infiuence ; consequently, 
our aim should be rather to procure asepsis than antisepsis. 
Assistants must be personally clean. They should have taken a 
thorough bath on the morning of the operation and should have 



84 GYNECOLOGY. 

seen no case of contagious disease prior to its performance. They 
should remove their coats and vests, roll up their clothing to the 
elbows, thoroughly scrub their hands and arms with soap and hot 
water, and wash in disinfectant solutions. Their clothing should 
be covered with clean sterile linen. They should subsequently 
avoid shaking hands or touching any objects not disinfected. 
The operator should postpone the operation if he has the smallest 
suppurating sore on his hands, or should wear a pair of rubber 
gloves, to prevent infection of the wound. 

125. Indications for Anesthesia. — The use of some anesthetic 
is necessary in the performance of many operations, and is of 
great advantage in all. In the virgin, in nervous patients, or 
those in whom the abdominal and pelvic organs are very tender 
from the presence of inflammation, the administration of an 
anesthetic renders an examination much more satisfactory to 
the physician and less distressing to the patient. 

126. Agents Employed. — In an examination it is undesir- 
able that the patient should be long under the influence of an 
anesthetic or should have a large quantity administered. Ether 
and chloroform are objectionable, first, because of the length of 
time required to secure insensibility and recover consciousness; 
second, the subsequent nausea and vomiting, which frequently 
last for hours. Nitrous oxid gas is an agent which produces 
prompt unconsciousness, and from which the patient as promptly 
recovers, but it requires a special, quite expensive, and rather 
unwieldy apparatus. 

Bromid of ethyl is almost as rapid in its effects as the nitrous 
oxid, requires but a small quantity, the patient regains con- 
sciousness almost immediately after the inhalation is discon- 
tinued, and its use is much less frequently followed by nausea 
and vomiting. It can be administered in one's office, and the 
patient shortly after return to her home, feeling but little the 
worse for her experience. This agent is very satisfactory for 
short operations, such as opening abscesses or dilatation of 
the urethra or anus. In very nervous patients it may precede 
the administration of ether or chloroform, whereby the stage of 
excitement and struggling is avoided. With the assistance of 
Dr. P. B. Bland I have been lately experimenting with the 
use of chlorid of ethyl, and find it acts very satisfactorily in 
producing quick anesthesia. This drug has been employed in 
the performance of serious operations, such as hysterectomy, 
etc. I myself have used it during the performance of various 
abdominal operations, having had patients under its influence 
as long as fifty minutes without any ill symptoms. It has not 
seemed to produce any uncomfortable sensations following 
the operation, although the anesthesia is not as profound and 



THERAPEUTICS. 



85 



durable as that induced by other anesthetics. For prolonged 
operations ether and chloroform are to be preferred. Ether is 
generally recognized as 
the safer drug. In the 
very young or the aged 
it is less satisfactory 
than chloroform, and 
probably not so safe. 
Chloroform should be 
preferred in the pres- 
ence of renal disturb- 
ance and when the pa- 
tient is suffering from 
emphysema or chronic 
bronchitis. Some of 
the French surgeons 
advocate the adminis- 
tration of \ of a gr. of 
sulphate of morphin 
and Y^-Q of a gr. of 
sulphate of atropin 
hypodermically about 
twenty minutes prior 
to the administration 

of chloroform, and they claim: (i) that it increases the safety by 
diminishing the danger of syncope; (2) that the patient is much 




Fig. 62. — White's Oxygen Apparatus, T\-hich can 
be Utilized for Anesthesia by Placing Anes- 
thetic in the Bottle. 




Fig. 63. — Northrup's Apparatus for Administering a Mixture of Chloroform 

and Oxvgen. 



less likely to suffer from nausea and vomiting; (3) that the 
patient, having taken a smaller amount of the vapor, recovers 



86 GYNECOLOGY. 

consciousness more quickly. The administration of a mix- 
ture of chloroform and oxygen, obtained by passing oxygen 
through a bottle of chloroform to the inhaler, decreases the 
danger of this agent and accomplishes anesthesia with the 
minimum quantity of the drug, without discomfort, with lessened 
nausea, and with slight subsequent distress. (Figs. 62 and 63.) 
The patient does not have the blanched appearance of the 
face, and rapidly recovers when its administration is suspended. 
We do not feel it necessary to describe the administration of 
the anesthetic further than to caution that false teeth and 
foreign bodies should, be removed from the mouth. 

127. Administration. — The patient should be directed to 
breathe deeply. She should be reassured by the physician, 
both in speech and manner. Talking upon the part of the 
administrator or attendants should be avoided. The pulse, 
respiration, and condition of the pupil should be continually 
observed. Dilatation of pupils, blanching of the face, arrested 
or stertorous breathing, and sudden feebleness of the pulse 
should indicate the temporary withdrawal of the vapor. Con- 
tinued syncope, particularly in chloroform narcosis, requires 
resort to artificial respiration, and often suspension of the pa- 
tient with head downward. The administrator of the anes- 
thetic should be provided with a hypodermic syringe, solutions 
of strychnin and atropin, and some nitrite of amyl. The latter 
agent is of advantage because of its rapid action as a primary 
heart stimulant, and its influence in dilating the arterioles by 
its action upon the vasomotor system. When chloroform is 
largely given, a bellows and mask, by which the lungs can be 
inflated with air, will not infrequently be effective in saving 
life. In suspended respiration forcible pulling upon the tongue 
acts as a respiratory stimulant. The inhalation of vinegar 
following anesthesia appears to lessen the tendency to nausea. 

128. Local Anesthesia. — General anesthesia is attended with 
danger in renal disease, in marked pulmonary changes, in fatty 
degeneration of the heart, and in atheroma of the large vessels. 
In such cases, and when general anesthesia is objectionable, 
local anesthesia may be employed. Freezing by ice and salt, 
by ether, or by ethyl chlorid spray may be utilized, but its 
application is limited. Continuous irrigation with carbolic acid 
has a benumbing effect upon the mucous surfaces, by which 
pain is obtunded. 

Cocain. — The most effective agent for local anesthesia is 
one of the cocain salts. In operations about the genitals or 
anus it is preferably given hypodermically, and for this pur- 
pose the phenate of cocain is the most satisfactory. It is slower 
in being absorbed, and is less likely to be a source of infection 



THERAPEUTICS. 87 

from the presence of micro-organisms. The injections should 
be made with a one or two per cent, solution, using as much 
as from one to three grains of the drug. The injection produces 
anesthesia for the distance of half an inch from the point of 
the needle; consequently a number of injections may be re- 
quired. This method of anesthesia has been effective in am- 
putation of the cervix, trachelorrhaphy, and operations upon 
hemorrhoids and fistula in ano. The drug sometimes has an 
alarmingly depressing effect. This symptom, it is said, may 
be avoided by combining nitroglycerin in the injection. When 
symptoms of depression occur, resort should be had to strychnin, 
atropin, alcoholic preparations, and nitroglycerin. 

Schleich, of Germany, after considerable experimentation, 
has suggested three solutions for infiltration anesthesia. The 
basis of all is a solution of two parts sodium chlorid, one-fourth 
part morphin hydrochlorate, in water one thousand parts, 
to which, for what is called the stronger solution, two parts 
cocain hydrochlorate are added — one part for the medium 
and one-tenth part for the weaker solution. The water and 
salt are sterilized by heat. A larger syringe than usual is used. 
The site for operation is carefully cleansed ; then, after numbing 
the surface with an ethyl chlorid spray, a puncture is made 
and fluid injected until a wheal the size of a dime is raised; 
the needle is introduced in its margin, and so continued until 
the entire length of the proposed wound is completed. The 
first puncture is the only painful one. The insensibility of 
the skin lasts for from fifteen to twenty minutes. 

Spinal anesthesia is secured by the injection of one to two 
grams of a sterilized (2 per cent.) solution of cocain into the 
spinal cavity. The injection is made between the lumbar 
vertebrae, and on a line level with the crests of the ilia. A 
long needle is introduced, the entrance of which into the spinal 
canal is indicated by the escape of spinal fluid. This form 
of anesthesia has been largely practised by Tufher, of Paris, 
who has observed no untoward symptoms and has found it 
very satisfactory in all operations below the diaphragm. In 
a patient who had had one kidney removed and the remaining 
one so diseased as to render the employment of a general anes- 
thetic unwise, under this method I opened up a sinus which 
extended down to the vertebrae and into the pelvis without 
pain to the patient, and without the depression and horrible 
nausea which had been associated with her previous operations. 
A second patient, a young girl, who had a large necrotic ovarian 
cyst, a portion of one lung consolidated, and a mitral murmur 
with beginning cardiac inefficiency, — factors which made her 
condition very unfavorable for ether or chloroform narcosis; 



88 GYNECOLOGY. 

Spinal anesthesia was employed, and I was able to remove 
the tumor without pain, and the patient had an uninterrupted 
recovery. 

129. Preliminary Details of Operation. — The presence of 
the patient, anesthetized, in the operating room presupposes 
the thorough preparation detailed in the previous paragraphs. 
A sufficient number of well-drilled assistants should have their 
duties assigned, so that the operation may proceed without 
confusion or delay. Instruments, ligatures, dressings, sterilized 
water, and sponges have been prepared. In abdominal opera- 
tions the number of sponges should be known, so that they 
may be accounted for before the wound is closed. It is also 
important to have a definite number of instruments, as both 
sponges and instruments, especially hemostatic forceps, have 
been left in the abdominal cavity. Every step of the opera- 
tion, to the minutest detail, should be conscientiously watched, 
for, as the chain is only as strong as its weakest link, so an 
otherwise perfect aseptic procedure may fail through a single 
flaw. I have seen the most careful preparations for an opera- 
tion, and the operator place his silk sutures upon a syringe box ; 
an assistant stroke his mustache, a nurse use her handkerchief, 
each instance being a break which imperils the result. 

130. Arrangement. — The instruments should be placed at 
the right of the operator, so that he can reach them as needed. 
The sponges should be in the care of a nurse upon the opposite 
side. The sponges and gauze should be removed from the 
receptacle and passed to the operator or his assistant by the 
nurse with a pair of forceps. After being used they should 
be placed in a basin. The nurse dispensing the sponges should 
keep an accurate record of the number given out, with which 
those returned should correspond. The wound should not be 
closed until it is certain all sponges have been removed. It is 
well to have one large, broad piece of gauze for walling off the 
intestines, or several smaller pieces may be employed and the 
end of each secured with a pair of forceps. A basin of sterilized 
hot water should be alongside the instruments for the hands 
of the operator, and his principal assistant should have another. 

131. Positions of Operator and Assistants. — In an abdom- 
inal section I prefer to stand on the patient's left, with my 
assistant opposite; the second assistant gives the anesthetic; a 
third looks after the instruments, ligatures, and sutures. One 
nurse attends to the sponges, a second changes the water in 
the basins, especially in those for the hands of the operator 
and assistant and prepares sterilized water or salt solution 
for irrigation. A third may be ready for emergency and have 
the dressings ready upon the completion of the operation. 



THERAPEUTICS. 



89 



132. Clothing of Patient. — The patient will be better to 
have all clothing removed, in order to prevent it becoming 
soiled during the operation. Clean blankets should be wrapped 
about the upper part of the body and the lower extremities. 



nurse: INITH 
SPONGELS 




Operating f\ooM 

FROM ^BOVE^ 




NURSE AT 
INSTRUMENT 
TABLE 



Fig. 64. — Arrangement of Tables and Assistants in Operating Room. 



These should be covered with sterilized towels, and over all a 
sterilized sheet, in the center of which an opening has been 
prepared for exposure of the field of operation. 



90 



GYNECOLOGY. 



133. Incision. — The linea alba is chosen for the site of in- 
cision in the majority of cases of abdominal section. A cut, 
varying in length from two to twelve inches, according to the 
condition for which the operation is done, is made with a sharp 
knife. When the abdomen is moderately distended with a 
growth, the first sweep of the knife should reach the fascia 
over the peritoneum. The operator and his assistant with 
long dissecting forceps pick up the peritoneum and cut it be- 
tween them, thus avoiding injury to the cyst, or, when the 
abdomen is undistended, a knuckle of intestine. 









T 




1 












.A 










'^-. 




1 

i 

% 

% 


k ■ 
\ 

■t 

V 


If 


,J- ^ . 







Fig. 65. — Abdominal Wall Incised; 
Peritoneum Picked up by Dis- 
secting Forceps. 



Fis:. 66. — Peritoneum Incised. 



As soon as the peritoneum is opened the atmospheric pres- 
sure carries the intestine out of the way, when the incision may 
be completed with a knife or with probe-pointed scissors, in- 
troducing two fingers as a guard. Should considerable bleeding 
occur after the first sweep of the knife, it can usually be con- 
trolled by pressure with a gauze pad wrung out of hot water. 
When this is insufficient, the bleeding vessels should be seized 
with hemostatic forceps. 



THERAPEUTICS. 



91 



The length of the incision has been a prolific source of dis- 
cussion. It has but little influence upon the result. It should 
be sufficiently long to permit the object of the operation to 
be accomplished with ease and as little irritation as possible. 
A long incision, if properly united, will be as firm as a short one. 

134. Adhesions. — In inflammation complicating a cyst it 
may be difficult to determine Avhen we are through the perito- 
neum. In case of doubt it is better to continue the incision 
until the cyst is opened, when the line of union can be more 




Fig. 67. — Scalpels. 



readily determined. It is well to remember that at the um- 
bilicus the peritoneum is closely united to the overlying tissue, 
and this fact may be utilized in cases of uncertainty. As far 
as possible, separation of adhesions should take place \inder 
the eye, by drawing them down to the incision. Vascular 
adhesions and every bleeding vessel should be secured with 
forceps or should be ligated. 

With the application of forceps the number of necessary 
ligations will be reduced, as the pressure will often prevent 
subsequent bleeding. The wound should not be closed if any 
large bleeding points are present. In short, firm intestinal adhe- 
sions the greatest 
safety is assured by 
keeping close to the 
cyst. In some cases 
it may be necessary 
to cut into the cyst, 
leaving a portion 

attached to the in- Fig. 6S. — Pressure Forceps. 

testine, always tak- 
ing the precaution, however, to remove its inner, secreting sur- 
face. 

135. Toilet of the Peritoneum. — In the removal of large 
cysts care should be exercised that their contents do not escape 
into the abdomen. If the contents are uncontaminated, con- 
sisting of thin, serous fluid, it should be removed by sponging 
only. It is difficult for me as an operator to get over early 
impressions. My education leads me to resort to abdominal 




92 



GYNECOLOGY. 



irrigation, preferably with normal salt solution, whenever 
infection is possible, but experience has demonstrated that 
patients do equally well when pus is sponged out as when irri- 
gated. It is a serious question whether the measures we often 
institute in the name of toilet of the peritoneum are not more 
prejudicial than helpful. When irrigation is done it is most 
effectively accomplished by pouring the belly full of normal salt 
solution, churning it about, pressing it out, and removing the 




Fig. 69. — Dissecting Forceps — Long Bladed. 



remainder with sponges. All bleeding points must be secured. 
If there is oozing from the surface, sponges wrung out of hot 
water should be packed firmly upon it until the operation is 
completed, when the}^ can be removed. If bleeding still con- 
tinues, the surface should be sponged with a hot solution 
(10 per cent.) of ferripyrin, or a spray of a 4 per cent, solution 
of antipyrin may be employed. Should hemorrhage be per- 
sistent, a gauze pack affords an efficient means of control. 

136. Drainage. — The question of drainage was formerly a 
momentous one. Keith's rule that it should be used only when 
there was something to drain was a good one, but with improved 
methods of technic we can depend more and more upon the 
natural absorptive power of the peritoneum. The employ- 
ment of the glass drainage-tube, which was formerly a matter 
of routine, is now more honored in the breach than in the ob- 
servance. When a glass drain- 
age-tube is employed, it should 
be from six to eight inches long, 
with a number of small perfora- 
tions at the lower extremity. 
These openings should be small, 
otherwise portions of intestine 
or omentum slip into them and 
become strangulated or render 
the removal of the tube pain- 
fully difficult. The openings should be smooth, and should be 
beveled at the expense of the outer surface. The lower end 
of the tube should be open; the external end should be pro- 
vided with a flange, over which a piece of rubber dam may 
be placed to prevent soiling of the dressings. The caliber of 
the tube should not exceed one-third of an inch. The use 




Fig. 70. — Glass Drainage-tubes. 



THERAPEUTICS. 



93 



of the drainage-tube required most exacting care upon the part 
of the nurse and the physician. Every precaution had to be 
exercised to prevent it becoming a gateway for the entrance of 
infection. It needed to be cleaned every half hour or oftener 
so long as there was any discharge. This was accomplished 
bv the use of a suction tube which reached to the bottom of 




Fig. 71. — Uterine Syringe for Cleansing Drainage-tube. 

the tube, or, better, by tube-forceps and pledgets of sterilized 
absorbent cotton. The frequent cleansing of the tube was 
avoided by passing a strip of sterile gauze to its bottom, which 
acted as a wick. 

137. Objections to Drainage. — The glass drain was objec- 
tionable because: (i) It obliged the patient to remain upon 




Fig. 72. — Tube Forceps for Cotton Pledgets. 



her back; (2) unless carefully placed it caused sufficient pres- 
sure upon the rectum to produce ulceration and even a fecal 
fistula; (3) it increased the difficulty in maintaining the wound 
aseptic, and afforded ingress to pathogenic germs, either through 
its cavity or along its sides; (4) it rendered the abdomen weak 
and increased the danger of ventral hernia; (5) it endangered 
the formation of a 
sinus which was long J-"^. 
in closing. The fre- V 
quency with which 
drainage was thought 
to be required, it was 
found, could be les- 
sened by the introduc- 
tion of large quantities of normal salt solution, by AA^hich the 
infectious material was diluted and rendered more readily con- 
trolled by the peritoneum. Later experience has demonstrated 
that such cases do equally well by careful walling-off of pus col- 




:ztf^ 



Fi.c 



-Gauze Wick in Drain. 



94 



GYNECOLOGY. 



lections with gauze before they rupture and then thoroughly 
removing the pus and blood with dry gauze. The peritoneum, 
if given an opportunity, will take care of infection ; the means 
which have been employed for the removal of infection have 
crippled the antagonistic processes of the peritoneum. 

138. Gauze Drain. — Drainage has been accomplished by 
a twist of gauze, or, where there was much oozing, by gauze 
pressure. The Mikulicz drain consisted of a piece of gauze 
with a string tied to its center, placed in the bottom of the 




Fig. 74. — -Mikulicz Drain. 



pelvis, within which strips of gauze were packed. These strips 
were ordinarily marked, to designate the order in which they 
were introduced. The pain in removing was greatly decreased 
by covering it with rubber tissue except at its extremity. Drain- 
age, whether by tube or gauze, is of but short duration, and 
its influence is confined to a limited area. Lymph exudate 
soon walls it off as a foreign body from the general cavity. 
The gauze is very efficacious as a tampon. Its pressure arrests 
hemorrhage and promotes the formation of exudation which 



THERAPEUTICS. 95 

closes oozing vessels and bars the avenues for the entrance of 
infection. 

139. Where Placed. — The drain, whether glass tube or 
gauze, was generally placed in the lower angle of the wound, 
though it could be placed between sutures at whatever part 
of the wound was most favorable. 

140. Postural Drainage. — The uninjured peritoneum is a 
very active absorbing surface, and Clark utilized the knowl- 
edge of this fact to avoid the introduction of a drain by ele- 
vating the foot of the bed eighteen inches for from twenty- 
four to thirty-six hours, by which the fluid gravitated away 
from the injured surfaces. The danger of infection was lessened 
by active irrigation with a large quantity of normal salt solution 
before the wound was closed. The activity of any pathogenic 
material remaining within the abdomen was diminished by 
dilution, through the retention of a considerable quantity of 
the solution when the wound was closed. 

This position also decreases the pain following an operation 
by the lessened quantity of blood sent into the vessels of the 
elevated pelvis. 




Fig- 75- — Gauze Drain Covered with Rubber Tissue. 

141. Closure of the Wound. — Before the sutures are intro- 
duced the omentum is generally drawn over the intestines. 
Formerly when extensive adhesions or purulent discharges 
were present the belly was left filled with a sterile normal salt 
solution. While we now urge the dry gauze sponge, it is yet 
difficult not to resort to the flushing with normal salt water 
when abscess cavities are ruptured. The wound can be closed 
by through-and-through interrupted sutures or with buried 
sutures in separate layers. The interrupted sutures of silk, 
silkworm-gut, and silver wire or chromic catgut are intro- 
duced through the entire thickness of the abdominal wall, 
about three-fourths to one inch apart, including one-eighth 
of an inch of the peritoneal and one-fourth of the skin surface 
on each side. Each suture is secured with a pair of hemostats, 
and after all are introduced the gauze pad placed over the 
intestines is removed, the cavity is inspected, and the sutures 
are tied. Care has to be exercised that a knuckle of intestine 
or a piece of omentum is not caught by the sutures. The most 
important consideration for the future of the patient is the 



96 



GYNECOLOGY. 



union of the aponeurosis, for upon its accurate union depends 
the subsequent strength of the abdominal wall. 

Edebohls closed the peritoneum, muscle, and aponeurosis 
with No. oo or No. o chromicized catgut. Beginning at the 
upper angle of the wound, a continuous suture was passed 
through the peritoneum and lower half of the muscle, until 
the lower angle of the wound was reached; then, returning 

with the same su- 
ture, the upper half 
of the muscle and 
the aponeurosis were 
united, tying to the 
free end at the up- 
per angle one knot 
for the double su- 
ture. A method of 
suturing has been 
suggested by Haughey, of Battle Creek, Mich., which consists 
of a continuous suture each of silkworm-gut for peritoneum, 
aponeurosis, and skin; the ends of each suture are brought 
out through the skin near the angle of the wound, and secure 
by perforated shot compressed over small aluminium plates. 
The skin suture is subcuticular. A more satisfactory method 
of wound closing, in my experience, is first to close the perito- 
neum with a continuous suture of catgut, which is left untied, 
then interrupted sutures of silkworm-gut, each of which in- 
cludes the entire wall above the peritoneum; before these are 




Curved and Straight Needles. 




Fig. 77. — Needle Forceps. 



tied the surface is carefully dried and the aponeurosis is ap- 
proximated and secured, the same piece of catgut which closed 
the peritoneum carried in the reverse direction, and the two 
ends are tied at the starting-point, thus making but one buried 
knot. The interrupted sutures are then tied sufficiently close 
to hold the surfaces snugly in apposition, without undue tension. 
142. Dressing. — After the wound is closed it is washed 
with alcohol and a sterile towel is pressed upon it, while the 
remaining surface of the abdomen is being cleansed and dried. 
The wound surface may be dusted with iodoform and boric 



THERAPEUTICS. 



97 



acid (i : 7), with acetanilid powder, which is fully as effective 
and much cheaper, w^hile free from disagreeable odor, or it 
does equally well without anything intervening betw^een it 
and the gauze. I prefer to place over the wound sterile gauze, 
upon which is placed a thick layer of sterilized nonabsorbent 
cotton, enveloped by a piece of sterile gauze, — all of w^hich 
are held in place with tapes attached to pieces of plaster, three 




Fig. 78. — I. Peritoneum Nearly 
Closed with Continuous Cat- 
gut. 2, Silkworm-gut Sutures 
through All Structures above 
Peritoneum. 3. Aponeurosis 
Being United with Continuous 
Suture of Catgut. 



Fi< 



-Silkworm-gut Sutures 
Tied. 



on each side, — and, finally, a sterilized bandage. The use of 
the tapes affords a ready access to the wound without annoy- 
ance to the patient. 

143. Postoperative Treatment. — The most frequent pro- 
cedures, both before and after an operation, which should 
receive consideration are the use of the hypodermic syringe 
and catheter. I have frequently seen serious septic processes 
7 



98 GYNECOLOGY. 

develop from the use of the hypodermic needle, and many 
patients suffer more from the careless use of the catheter than 
they did from the condition for which the operation was per- 
formed. 

144. Precautions in the Use of the Hypodermic Syringe. — 
In the use of the hypodermic syringe there are four sources 
of infection: (i) The hands of the operator; (2) the instrument; 
(3) the fluids to be injected; and (4) the skin of the patient. 
The syringe is difficult to keep aseptic. The metal instrument 
may be boiled in a soda solution. If you have a glass instru- 
ment the piston should be withdrawn and it and the barrel 
should be placed in a five per cent, solution of carbolic acid; 
the needles, if platinum, may be passed through an alcohol 
flame, but ordinary needles would be destroyed, and, therefore, 
they should be boiled. Solutions of atropin, morphin, cocain, 
strychnin, and ergot in favor the development of bacteria, and 
when kept for some time, will be found swarming with micro- 
organisms. Cocain may be kept in a (i : 10,000) bichlorid 
solution; the others named may be preserved by the addition 
of a few drops of carbolic acid to the ounce of solution. Prob- 
ably the safest method is to make up the solution of morphin, 
atropin, or strychnin from tablets, which can be dissolved by 
boiling without affecting the action of the drug. 

145. Catheterization.— No procedure, fraught with so much 
discomfort to the patient when carelessly employed, is so fre- 
quently performed with so little consideration as is the use of 
the catheter. We have to regard not only the distressing 
symptoms produced by infection of the urethra and bladder, 
but also the serious results of extension of the disease to the 
ureters and pelves of the kidneys. Fortunately, the female 
urethra is short, and permits the use of a glass catheter, which 
can be kept clean. The instrument should be scalded before 
and after being used, and should be kept in a five per cent, 
solution of carbolic acid during the intervals. It should be 
free from cutting edges. 

The labia should be separated to expose the urethral orifice, 
when the vestibule should be sponged with a solution of boric 
acid or sterile water. The catheter should be gently introduced. 
Should the urethra become painful or irritation of the bladder 
occur from frequent use of the catheter, the bladder should be 
irrigated with a hot boric acid solution. After an abdominal 
operation the catheter need not be used for twelve hours, un- 
less the patient experiences much distress. 

146. Comfort of Patient. — Immediately after the opera- 
tion the patient is placed in bed, covered warmly, protected 
from draft, and kept quiet; the room should be darkened. If 



THERAPEUTICS. 99 

the operation has been protracted or the patient is depressed, 
hot-water bottles should be placed about her to maintain the 
body-heat. These bottles should be tightly corked and a 
blanket should be placed between them and the skin. The 
patient, unable to understand or to make known her discom- 
fort, may be badly burned if such precautions are not exercised. 
As she recovers, it becomes very irksome to remain in one 
position. An attentive nurse can greatly add to her comfort 
by passing her hands under the patient so that cool air reaches 
the heated back, by changing her from one side of the bed to 
the other, and by keeping the clothing under her smooth and 
dry. Unless there is some especial contraindication, as the 
presence of a drainage-tube, she may be turned upon her side. 
The nurse can accomplish this in part and can give great com- 
fort to the patient by raising the mattress and slipping pillows 
under it, thus resting the back. One of the earliest symptoms 
of which the patient complains is intolerable thirst. It is 
better to limit the quantity of liquid for the first few hours to 
small quantities of hot water — a half ounce every hour, given 
with a horn spoon, as the china cup would burn the lips. Ice 
should not be given; it increases the thirst and the patient 
will not be content without a piece constantly in her mouth. 
Both mouth and stomach soon become irritated. When the 
patient does well, she can have a cup of tea or coffee on the 
morning following the operation, small quantities of ice-water 
or soda-water, a teaspoonful of beef -juice every three hours; 
and on the second day light food, and by the end of the week 
a generous diet. 

147. Vomiting should be an indication to discontinue every- 
thing by the mouth. Enemas of warm water, six to eight 
ounces, may be given to assuage thirst, and when the patient 
is in need of nourishment, nutrient enemas may be given every 
three or four hours. Nausea and vomiting occur very fre- 
quently after an operation and may continue several days. 
The ejected material may be the fluid which has been ingested, 
or bile, mucus, or the contents of the small intestine. The 
application of a mustard plaster and an enema of 30 grains 
of chloral and i dram of potassium bromid in 2 ounces of warm 
water will often be sufficient to quiet the irritability. If the 
patient is constantly retching, it is better to give a large draft 
of water with i dram of bicarbonate of soda, a cup of weak 
tea, or some soda-water. 

Professor Hare has suggested 2 grains of acetanilid and 
I of a grain of caffein citrate, to be repeated in two hours. I 
have found this formula of advantage in vomiting following 
etherization. Other remedies of more or less value are : cocain 



100 GYNECOLOGY. 

(4 per cent, solution) 3 drops every hour; tincture of nux 
vomica, 2 drops every hour; 2 drops of compound tincture 
of iodin and f of a grain of carboHc acid every hour; or i 
drop of Fowler's solution every half hour. The earlier the 
bowels can be evacuated, the sooner will the offensive material 
be removed; hence, the most effective treatment will be the 
administration of a saline, or, when it can not be retained, 
the use of calomel, alone or in combination with bicarbonate 
of soda, 5 grains of the latter to from J to i grain of the former, 
every hour until evacuation of the bowels occurs or until eight 
doses have been taken. In frequent vomiting a Seidlitz powder 
is very efficient. If vomited, it generally empties the stomach, 
and when retained, starts the current through the canal. 

If the intestine is distended and has not yielded to enemas or 
to the purgatives suggested, and the patient is constantly vomit- 
ing small quantities of dark fluid, nothing will give quicker or 
more lasting relief than irrigation of the stomach through a 
stomach-tube. When it is evident that the vomiting is an indi- 
cation of peritonitis, it is wiser to discontinue purgatives and 
be content with lavage. No food, not even water, should be 
given by the mouth, and peristalsis should be arrested by small 
doses of morphin hypodermically. Rectal feeding may be re- 
quired because of irritable stomach and the enfeebled condition 
of the patient, and especially in conjunction with the treatment 
suggested for peritonitis. 

Peptonized milk or broth may be given every three or four 
hours. When the patient is much depressed, a normal salt solu- 
tion and whisky or bovinin in combination may be given. When 
rectal feeding is practised, the bowel should be irrigated once 
or twice daily. 

148. Tympanites may be the result of a passive collection of 
gas in the intestines, or may indicate the development of peri- 
tonitis. The early passage of flatus is always an encouraging 
symptom. The sensation of distention may be promptly met 
by the use of an enema of — 

Magnesia sulph., ^ 

Glycerin, y aa ^ j . 

Water, J 

If relief is not secured, an enema of two tablespoonfuls of 
turpentine beaten up with the yolks of two eggs and strained 
into a quart of soapsuds should be administered. Keith recom- 
mends an enema consisting of six grains of quinin dissolved in 
four drams of whisky and two ounces of warm water, to be 
given every two hours until three doses have been administered. 
This prescription stimulates the nerve-centers and favors peris- 



THERAPEUTICS. 101 

talsis. The most effective agent to influence increased peristalsis 
is an enema consisting of an ounce of powdered alum dissolved 
in a quart of hot water. If peristaltic action is marked, but 
reversed, lavage should be employed, a hypodermic injection of 
morphin given, and followed, after a rest of three or four hours, 
by a repetition of the quinin. 

149. Shock. — Severe shock should be combated by the use 
of artificial heat, enemata of coffee and stimulants, suppositories 
of ice, elevation of the foot of the bed, bandaging the limbs, and 
the injection of normal salt solution into the buttocks, beneath 
the scapula, or directly into a vein. Hypodermic injections of 
str3^chnin (gr. -^-q-^) should be given according to the urgency 
of the condition; w^hen the shock is profound, the patient may 
be supported by the hypodermic administration of testicular 
fluid in twenty-minim doses three or four times daily. Digitalin 
(gr. xV~i) i^ay be given every eight hours, atropin (gr. y^) 
twice daily, or (i : looo) solution adrenalin chlorid gtt. x-xx 
every two hours. 

150. Anodynes. — The patient should be encouraged to bear 
the pain without an anodyne. When the pain is very severe, 
it may be allayed by the rectal use of chloral, 30 grains in two 
ounces of warm water. 

When the patient is very much distressed, it may become a 
choice between the two evils — morphin or restlessness; and a 
hypodermic injection of from I- to i of a grain should be given. 
Morphin decreases peristalsis and favors tympanites, and conse- 
quently should, if possible, be avoided. 

151. Internal hemorrhage, if the technic is perfect, should 
not occur. Its existence will be indicated by paleness of lips, 
feeble or absent pulse, sighing respiration, and clammy perspira- 
tion. The use of strychnin or the injection of salt solution 
favors the increase of hemorrhage. The only proper treatment 
is the prompt reopening of the wound and the ligation of the 
bleeding vessel. 

152. Removal of Sutures. — The sutures in an ordinary case 
should be removed about the seventh or eighth to the tenth 
day. If the patient has had a complicated convalescence, the 
union Avill not be so firm, and it would be better not to remove 
them until the end of two weeks. If the sutures are pulling 
and causing pain, a part of them may be removed. The same 
care regarding cleanliness and avoidance of sources of infection 
should be practised as in the operation. The sutures introduced 
as suggested by Haughey need not be removed for ten days 
or two weeks. The suture is drawn up for an inch at one end, 
cut, and the remaining portion withdrawn. The middle suture, 
unless carefully placed, will sometimes be difficult of removal. 



102 GYNECOLOGY. 

A few days' delay will generally facilitate its removal, or it 
may be secured to a piece of elastic, which will make continuous 
traction. Leaving the sutures long (see Fig. 79) will facilitate 
their removal and dispense with the necessity for forceps to 
lift up the knot. The wound should be dressed as in the begin- 
ning. 

153. When Permitted to Get Up. — The patient should not 
be permitted to sit up in bed prior to the sixteenth or eighteenth 
day, and then only for a few minutes, resting upon a bed-rest. 
The time may be increased each day, and she can be lifted out 
upon a chair at the end of the third week. 

154. Plastic Operations. — In plastic operations the same 
precautions in cleanliness must be observed. Sponging can be 
replaced by the use of continuous irrigation. The parts may 
be dusted with acetanilid or iodoform and boric acid. The parts 
should be dressed with sterilized gauze held in place by a bandage. 

Vaginal irrigation should not be practised during the first 
forty-eight hours subsequent to an operation, for it interferes 
with the sealing of the wound by plasma. The patient should 
be confined to bed at least two weeks, and in perineal operations 
three weeks are preferable. In combined uterine, vaginal, and 
perineal operations the internal sutures, if nonabsorbable, should 
remain for three or four weeks. I prefer chromic catgut for all 
plastic work, for the reason that the patient is spared the dis- 
comfort of the removal of sutures, and the newly united tissues 
are not subjected to the strain. 



MEDICAL TREATMENT. 

155. General Treatment. — In every case of genital disease it 
is very important that the various organs of the body should be 
carefully interrogated as to the performance of their functions. 
It is a hopeless task to attempt to treat the disease of one organ 
of the body as if it were not an integral part of the whole, and 
capable of producing reflex effects upon organs near or remote, 
or of being itself the seat of reflex conditions. Engorgement of 
the hepatic system and the consequent hemorrhoidal congestion 
must be corrected. This is effected by purgatives, laxatives, and 
alteratives. The patient should have calomel (gr. -^-^) or podo- 
phyllin (gr. -^-^) at night, followed the next morning by a Seid- 
litz powder, Rochelle or Epsom salts, phosphate of soda (5ij), 
or a wine-glass of Hunyadi Janos or Friederichshall water. If 
the liver is particularly sluggish, frequent apphcations of hot 
water over the hepatic region should be made. Ammonium 
chlorid or potassium iodid internally may be of service. 



MEDICAL TREATMENT. 103 

Efficient action of the kidneys should be secured by the 
use of diuretics, or want of action should be compensated by 
increased action of the bowels and skin. As anemia is a frequent 
accompaniment, the administration of the reconstructives, such 
as quinin, strychnin, arsenic, mercury, the bitters, and, in proper 
subjects, when the system has been prepared, the use of iron. 

Because of the profound effect this class of diseases exert 
upon the nervous system, the antispasmodics have found favor. 
In many cases the valerianate of zinc, asafetida, and the bromid 
salts will prove very grateful. In very nervous and anemic 
patients the cold pack, followed by massage, will be exceedingly 
beneficial. The state of the stomach, the heart's action, and the 
character of the respiration should always receive consideration. 

156. Specific Remedies. — The remedies which may be con- 
sidered as specifically uterine in their action are ergot, hama- 
melis, hydrastis canadensis, and viburnum prunifolium. 

Ergot is generally given in hemorrhage. It acts in two ways : 
(i) By stimulating the nonstriated muscle-fiber of the blood- 
vessels, increasing the rapidity of the circulation; (2) its direct 
action upon the uterine muscle, by which compression is made 
upon the vessels and a mass within the uterus is gradually 
extruded. 

A satisfactory prescription is — 

R.. Ext. ergot.. f .^ j 

Ext. hamamelis, \ 55 f?cc \\ 

Tr. cinnamomi, ) ^^ *5ss. M. 

SiG. — f^j every two or three hours. 

This combination is generally more effective than the ergot 
used alone. If the contractions are painful, one or two drops of 
the fluid extract of cannabis indica will be of benefit. 

Hamamelis and hydrastis undoubtedly owe their action to 
the large amount of tannic acid they contain. Hydrastin or 
hydrastinin, in doses of from |- to J of a grain, is more effectual 
in controlling hemoiThage than the fluid extracts. 

Viburnum prunifolium has been greatly vaunted as a remedy 
for the relief of dysmenorrhea or the arrest of threatened abor- 
tion, but I have never been able to obtain any perceptible value 
from its use. 

The extract of thyroid gland seems to exercise a specific 
influence upon the uterine mucous surface. In women who are 
very obese and have associated with the condition amenorrhea, 
or very scanty flow and sterility, the administration of the 
thyroid extract, in addition to the reduction of flesh, increases 
the flow, and frequently appears to overcome the sterility. The 
late Dr. E. H. Coover, of Harrisburg, found thyroid extract very 
effective in allaying the pain of advanced carcinoma of the 



104 GYNECOLOGY. 

uterus. He also thought that it had an influence in delaying 
the progress of the disease. This opinion seems in harmony 
with the observations of Beatson and others in carcinoma of 
the mammary gland. 

Thyroid extract is frequently of value in producing an im- 
provement in the conditions which occasion uterine hemorrhage, 
whether these be from interstitial endometritis, submucous 
fibroma, or carcinoma. Marked changes in the nutrition and 
the reduction in the size of myomata have been claimed for 
the use of this drug. 

Adrenalin, or extract of the suprarenal gland, through its 
action upon the involuntary muscular fiber, exerts a decided 
influence upon the uterine circulation. It is consequently a 
valuable addition to our armamentarium for the control of 
hemorrhage. 

Apiol, and the manganese salts, cause a hyperemia of the 
uterine mucous membrane, as indicated by increased normal 
menstrual flow, and its return in amenorrhea. 

157. Rest and Exercise. — It is very difficult to fix definite 
rules to guide a patient as to the amount of either rest or exer- 
cise she should take. What one person may regard as a pastime, 
another will consider violent exercise. Women with inflam- 
matory or engorged uteri are benefited by certain hours of rest 
each day. The recumbent position permits the blood-vessels 
to secure relief. Not infrequently, relief is enhanced by ele- 
vating the foot of the bed or by resting the pelvis upon a firm 
pillow. In predisposition to hemorrhage from fibroid growths, 
the patient should be kept in bed for a few days prior to, and 
during the menstrual period. Rest is obligatory in all acute 
inflammatory troubles. Some patients will, however, have 
to be stimulated to take exercise; they are disposed to go to 
bed on the slightest provocation, and remain so long that 
their muscles become flabby and the vessels grow feeble; the 
patient becomes bedridden, and every effort of exertion is at- 
tended with real or imagined pain. Such patients may require 
resort to massage and electricity to enable them to resume 
their ordinary duties. 

Judicious use of the bicycle or encouragement to play golf 
will be found most valuable auxiliaries in nervous patients 
who are dominated by imaginary aches and pains. The in- 
creased oxygenation and elimination without doubt free the 
patient from the cause of her distress. 



LOCAL THERAPEUTICS. 105 



LOCAL THERAPEUTICS. 

158. Baths. — The sitz-bath of hot water in inflammatory 
and congestive conditions is capable of giving great comfort. 
This should be followed by rest, and it would be contraindicated 
where there was a tendency to hemorrhage or in a possible preg- 
nancy. In neurotic patients, a systematic course of hydro- 
therapy will frequently prove restorative Avhen all other means 
have proved futile. 

159. Douche. — The value of the hot douche was made 
known by Emmet. It should be given with a gravity syringe 
while the patient is in a recumbent position; the more pro- 
longed, the larger the quantity, and the higher the temperature 
(115° to 120° F.), the more enduring will be the effect. The 
ordinary fountain syringe, a large vessel with a tube leading 
from its lower end, or an ordinary pitcher with a rubber tube 
carried to and held at its bottom by a weight, may be used. 
Instead of the ordinary rubber, wooden, or metal nozle, a glass 
end-piece is preferable, as it can be more readily cleansed. 
When preferred, the water may be medicated with astringents, 
such as alum, sulphate of zinc, acetate of lead, hydrastis, or 
hamamelis; or with antiseptics, as boric acid, carbolic acid 
(two to five per cent.), or permanganate of potash (one to two 
per cent.). The difficulty of saving the clothing from staining 
renders the use of the latter agent less frequent. Creolin (one 
to four per cent.) and acid sublimate (i : 5000 to i: 2000) are 
valuable. The antiseptic injections are of especial value in 
vaginal discharge, more particularly when of a specific character. 

The advent of menstruation is considered as contraindicating 
irrigation, but it may be resumed before it ceases, particularly 
when the odor is oft'ensive or the parts are irritated, using plain 
water, at a temperature of 100° F. If the vaginal discharge 
is particularly offensive, as in malignant disease, a douche, 
of thymol solution, one or two per cent., is a most excellent 
deodorizer. 

Astringent douches are used in excessive vaginal secretion, 
but should not be used when the patient is wearing a pessary, 
as the salts are deposited upon the instrument, roughen its 
surface, and thus increase the irritation. 

Rectal douches may be employed to cleanse the bowel, 
and for the relief of inflammation of the rectal mucous membrane 
or for their effect upon the neighboring pelvic organs. The 
close proximity to the uterus and broad ligaments, and the 
ability to retain the fluid longer in contact, make the use of 
the rectal enemata of hot water of especial value. Aledicated 



106 GYNECOLOGY. 

enemata are used to unload fecal accumulations for the relief 
of tympanites, and to medicate local inflammations. 

Vesical douches are used for the relief of inflammatory dis- 
ease of the bladder and urethra. 

1 60. External Applications. — In acute inflammatory con- 
ditions the popular plan of treatment is to employ hot applica- 
tions, but we have in the ice-bag a far more efficient means 
of allaying pain and of limiting the area of inflammation. Its 
persistent application will in many cases secure resolution in 
what would otherwise prove a serious disorder. The ice-bag 
over the sacrum affords prompt relief of dysmenorrhea of the 
congestive form. 

161. Counterirritants are productive of benefit in the more 
chronic forms of disease. Painting the skin over the lower 
abdomen with tincture of iodin is more frequently resorted to. 
It may be repeated and continued so long as the skin will bear 
it. The irritation is increased by the addition of croton oil. 

H. 01. tiglii, f^j 

Tr. iodin., f ^ij 

Etheris, f 5 v. M. 

SiG. — -Apply Avith brush externally. 

It produces a crop of pustules, which should be allowed to 
dry before the application is repeated. 

The most effective procedure is the application of a blister 
over the seat of pain or to the inflammatory exudate two or 
three times a month, but this should not be practised when 
the patients are much depressed or very anemic. 



Fig. 80. — Butt Uterine Scarifier. 

162. Bloodletting. — The general abstraction of blood is 
now rarely practised. Doubtless there are many cases in 
which a good bleeding would cut short a severe illness or abort 
an inflammatory attack. The local abstraction of blood by 
the use of a scarifler or by puncturing the cervix will often 
prove effective in relieving the pain of engorgement and in 
promoting absorption and resolution of inflammatory conditions. 

163. Local Applications. — A few years ago the routine 
treatment was the introduction of solid silver nitrate into the 
uterine cavity, the use of fuming nitric acid, and other power- 
ful caustics. Such treatment cured by destroying the glan- 
dular tissue of the part. Milder measures are now practised. 



LOCAL THERAPEUTICS. 107 

It should be an accepted rule that no intra-uterine medication 
should be practised unless the uterine canal is freely open to 
permit of thorough drainage. 

Applications to the uterine cavity are made by ^Yrapping 
a probe or applicator with absorbent cotton, which, after being 
saturated with the medicinal aeent, is carried into the canal. 



^=^d 



Fig. Si. — Aluminium Uterine Applicator. 

A few^ drops of the medicinal agent may be introduced by the 
long pipet. In the use of either procedure it is desirable that 
the cervix shall be freely opened, and the uterus in good posi- 
tion. If not, the medication will produce uterine contractions 
which will result in violent colic. Such attacks not infrequently 
are followed by severe inflammation of the adnexa and even 
of the peritoneum. To render intra-uterine treatment of value 




Fig. 82. — Long Glass Pipet. 

the plug of thick mucus which generally fills up the diseased 
cervix must first be removed, in order to permit the contact 
of the medicinal as:ent with the affected surfaces. 

164. Various Agents. — The agents generally applied locally 
may be classified as antiseptic, astringent, and caustic. The 
antiseptic applications are the combination of carbolic acid, 
creasote, iodin, and iodoform. Useful preparations are: 

H . Acid, carbolic, oSS 

Tr. iodini, f 5 j. M, 

R . Creasoti, ^ 

Glvcerin., v aa f 5ss. 

Alcohol., J M. 

An astringent eft^ect can be secured by a combination of 
tannin, as: 

R . Acid, tannic, 3 j 

Tr. iodini, \ 55 f ^i AT 

Glycerin., j aat^j. M. 

The most frequent applications are the tincture of iodin 
and Churchill's tincture. 



108 



GYNECOLOGY. 



Iodoform may be used in the form of crayons, as an oint- 
ment, or as a powder, with the insufflator. The various as- 
tringents may be apphed in powder alone or in combination 
with boric acid, iodoform, or acetaniHd. 

165. Astringents. — -The most available astringents are alum, 
borax, sulphate of copper and sulphate of zinc, the tincture 
of the chlorid of iron, fluid extract of hydrastis, and fluid 




Fig. 83. — Insufflator — Straight Stem. 



extract of hamamelis. The solid substances are best used in 
mild solution. Some of these agents when used without dilution 
are strongly caustic. 

166. Caustics. — Crayons of sulphate of zinc (fifty per cent.) 
are very effective for caustic purposes, and are used in aggravated 
forms of endometritis. Still more effective is the chlorid of 
zinc in crayons (thirty-three per cent.). 

Liquid caustics are nitric acid, acid nitrate of mercury, 
sulphuric acid, hydrochloric acid, chromic acid, solution of 
zinc chlorid, solution of silver nitrate, tincture of iron chlorid, 
carbolic acid, and creasote. It is exceedingly infrequent that 
the more active caustic agents are required. 

167. Tampons made of absorbent cotton, lamb's wool, or 
gauze afford an efficient method of treating the cervix. The 

best tampon is composed of a 
_._ combination of gauze and cotton 

or lamb's wool. It should have a 
thread attached, by which it can 
be withdrawn. The tampon may 
consist of simple sterilized mate- 
rial or may be medicated with 
antiseptics, astringents, styptics, 
anodynes, or alteratives. The 
principal purpose of the tampon 
is to sustain the uterus at a higher 
level, which relieves the patient from the dragging pains due to 
want of support of a heavy organ, and the change of position 
improves the circulation; the addition of an antiseptic permits 
it to be retained for a longer period without becoming foul. 
Sublimate, from its tendency to irritate the vagina and vulva, 



W--^' 



l^,^<"^ 




Fig. 84. — Tampon. 



LOCAL THERAPEUTICS. 109 

can not be satisfactorily used. Carbolic acid, boric acid, and 
iodoform are most satisfactory. The addition of glycerin is 
of value. By its affinity for the watery portions of the blood 
it produces a profuse discharge, which depletes the vessels 
and favors the absorption of exudates. The boroglycerid, 
glycerite of tannin, and a ten to twenty per cent, solution of 
ichthyol are popular applications upon the tampon, but the 
patient should be cautioned, in the use of the two latter, to 
wear a napkin in order to prevent her clothing from being stained. 
Besides supporting the uterus, the tampon may be used 
to control hemorrhage or discharge; to complete the diagnosis, 
through the discharge which it induces; to assist in maintain- 
ing the uterus in a normal position; and to prepare the way 
for the use of a pessary. 

1 68. Massage. — General massage affords an effective means 
of promoting nutrition and of improving the condition of pa- 
tients suffering from chronic pelvic troubles. It increases 
the number and the activity of the red blood-corpuscles, carries 
oxygen to the remote tissues and organs, facilitates oxgenation 
and combustion, and favors absorption, but, best of all, it im- 
proves the nerve tonus. Many patients are incapacitated by 
illness, by aggravated pains, or by disinclination to take exer- 
cise. Judiciously regulated massage accomplishes the con- 
stitutional changes ordinarily effected by exercise, free from 
its possible deleterious influences. Slowly the individual is 
rehabilitated, and as she gradually and insensibly resumes 
her self-control, she is emancipated from the pre-existing un- 
fortunate nerve phenomena. 

169. Pelvic Massage. — The beneficial results of massage 
in local inflammations of joints and superficial portions of 
the body justified the hope that it might be practised with 
advantage in the conditions of acute and chronic exudations 
within the pelvis. It has been systematized into a recognized 
procedure, known as pelvic massage, largely through the study 
and experiments of Thure-Brandt, a Swedish masseur. 

It is practised by having the patient lie upon her back upon 
a couch or table, with her buttocks close to its edge; the limbs 
are flexed upon the body. One or two fingers of the left hand 
are introduced into the vagina, with which the uterus is gently 
pushed forward against the anterior abdominal wall. The 
fingers of the right hand are placed upon the abdomen, and 
are moved in a circulatory or rotatory manner over the sur- 
face, or, rather, moving the surface with them in this manner 
(Fig. 85). The greatest gentleness must be exercised in the 
beginning, increasing the pressure as the patient becomes 
reassured or as the pain is lessened. As we progress, the fin- 



110 GYNECOLOGY. 

gers may be made to dip down, to push off and separate ad- 
herent organs, and to follow lines of cleavage indicating in- 
flammatory adhesions. The seances vary in length from five 
to fifteen minutes, the shorter time being preferable in the 
earlier applications, and they should be repeated from three 
times weekly to once daily. The exercise of this procedure 
will be found to produce a rapid alteration in inflammatory 




. 85. — Position of the Fingers in Pelvic Massage 



accumulations, setting free the uterus and its adjacent organs. 
The procedure will be indicated in all subacute and chronic 
inflammations of the pelvic organs unassociated with pus for- 
mation ; in displacements, when fixed by inflammatory adhesions ; 
in subinvolution and hypertrophy of the uterus from chronic 
interstitial inflammation; and in relaxation of the pelvic floor 
induced by increased weight of the pelvic organs. 



ELECTRICITY. Ill 

It is contraindicated in the presence of pus formation, 
whether contained in the tubes or within the pelvic tissues. 

Massage is rendered difficult by thick abdominal walls, 
and in nervous, hysteric women. In the latter, however, much 
may be done by gentle procedure until the patient's confidence 
and cooperation are secured. 



ELECTRICITY. 

170. Forms.— The immense influence exerted by the use 
of electricity in the development of the arts and sciences nat- 
urally has led to its study and utilization in the treatment 
of disease. The various electric currents were early employed 
in an empiric way in gynecology. It remained for Apostoli, 
however, to formulate plans for their more accurate dosage 
and systematic use. The principal forms in which the electric 
current is generated and" applied are Franklinic, galvanic, 
faradic, sinusoidal, and Ront genie. 

171. Franklinism. — Franklinism, or the static current, is 
the employment of electricity generated by friction. It is 
not generally used, but is an excellent nerve stimulant and 
counterirritant ; from the use of which great benefit has been 
claimed in cases of hysteria and neurasthenia. It has aft'orded 
the greatest service to patients in whom the local pelvic lesions 
are slight or difficult to recognize, w^hile the element of pain 
is a marked factor. It has been employed with advantage 
in amenorrhea, dysmenorrhea, ovarian, lumbar, or lumboabdo- 
minal neuralgia, vaginismus, hyperesthesia, and various neu- 
rasthenic conditions. The seances may be continued from 
six to thirty minutes. The number of applications is indefinite. 

172. Galvanism. — The galvanic current has an extensive 
field for its application in the treatment of diseases of the pelvic 
organs. As a therapeutic agent its eft'ects are recognized as 
polar, interpolar, and general (Martin). The polar eft'ects are 
acid and alkaline at the respective poles. In very strong cur- 
rents the action becomes caustic. The positive pole is a pow^er- 
ful sedative to the sensory nerves, and acts as a vasoconstrictor 
of the blood-vessels in its vicinity. As a result of the accumu- 
lation of certain salts frora the metal electrode emplo3^ed, it 
proves destructive to germs. The negative pole with current 
of proper density causes liquefaction of the tissues, and if the 
current is very strong, it exerts an alkaline caustic action. 
It is a powerful irritant to the sensory nerves of the parts, and 
also acts as a vigorous vasodilator of the blood-vessels. Inter- 
polar action consists of electrolysis and cataphoresis, or transfers 



112 



GYNECOLOGY. 



all fluids in bulk from the positive to the negative pole. Gal- 
vanism in its general effect, when forced through a portion 
of the body acts as a tonic to the entire system. The beneficial 
influence of the agent in gynecology is most effectively dis- 
played in the treatment of chronic endometritis, pelvic inflam- 
matory exudates, and in some varieties of fibroid tumors. 

173. Apparatus for Application. — The investigations of 
Apostoli demonstrated that the application of high powers 




Fig. 86. — Portable Galvanic Battery with Galvanometer. 



of electricity resulted in the destruction of tissue in which 
acid materials were found about the positive pole, while alkalies 
collected at the negative. The former caused a dry, brownish 
eschar; the latter, a soft, watery, elastic slough, which did 
not contract. The resistance of the skin required for the use 
of high powers a large, inactive electrode externally. Apostoli 
devised and employed a moist clay pad. Other operators 
have used a bladder or other animal membrane filled with 



ELECTRICITY. 



113 



a salt solution, or a large metal disc covered with wet cotton 
or a towel for the external electrode. The internal electrode 
may be vaginal or intra-uterine. The former may consist of 
a knob or a nest of knobs, from which a suitable one can be 
selected and attached to a gutta-percha-covered metal rod. 
The intra-uterine electrode may consist of a platinum Avire 
or a steel rod insulated to within one or two inches of its end. 
The insulating sheath of gutta-percha or celluloid may be mov- 
able and thus permit a variable surface to be subjected to the 
application. 

A battery, either portable or stabile, will be required cap- 



Fig. 87. — Intra-uterine Electrode with ^lovable Insulating Cover. 

able of generating a current of from 200 to 400 milliamperes, 
and so arranged that the strength of the current can be gradually 
increased. It should be provided with a galvanometer or a 
milliamperemeter to measure the current; a rheostat, by Avhich 
the strength of the current can be governed; a commutator, 
to permit a change of poles without removal of the electrodes 
(as a reversal of the poles can not be made without shock, 
the precaution should be exercised to greatly reduce the in- 
tensity of the current before such a change is made). 

174. Method of Procedure. — Apostoli's employment of the 
electric current requires a careful examination and an accurate 




-Vasfinal Electrodes of Different Sizes. 



diagnosis. If a growth, careful measurement from various 
fixed points should be made in order to be able to determine 
the results of treatment. The hands, genitalia, and electrodes 
must be thoroughly cleansed or disinfected. 

Before the external electrode is applied the skin should be 
carefully examined and all broken places covered with collodion 
or plaster; otherwise the electrode will be unendurable. 

The internal electrode should be introduced without the' 
speculum. The patient should be apprised that there will 
be a slight burning, and that there may be a bloody discharge 
8 



114 GYNECOLOGY. 

subsequently. Her clothing should be loosened, her corsets 
removed, and the bladder and lower bowel emptied. The 
application should not follow a full meal. 

While the electrodes are being introduced the current should 
be closed, and gradually opened subsequently. The first ap- 
plication should be carefully made with the purpose to deter- 
mine the patient's sensibility. The pole used for the active 
or intra-uterine electrode must depend somewhat upon the 
existing conditions. The positive pole possessing the most 
electrolytic action, and being an effective hemostat, should 
be employed for hemorrhage. The negative pole acts like an 
alkali, is the most painful, and is used to decrease the size of 
a growth or to enlarge a stenosed canal. The duration of the 
applications may vary from three to ten minutes. The num- 
ber of applications for an individual case is difficult to fix — 
generally from twenty to thirty. Their frequency is dependent 
upon the condition, varying from every eighth day to two or 
three times weekly. 

175. Indications. — The employment of galvanism is advocated 
in amenorrhea, dysmenorrhea, and menorrhagia; in chronic 
inflammation dissociated with suppuration; for the arrest of 
hemorrhage, relief of pain, and decrease of size in myomatous 
growths of the uterus, particularly in the submucous and inter- 
stitial varieties; and for chronic ovarian inflammation. This 
agent seems particularly valuable in women suffering from 
bleeding fibroids near the menopause, in whom the conditions 
render a radical operation unjustifiable. 

176. Contraindications. — ^According to iVpostoli, the galvanic 
current is contraindicated in the following conditions: (i) 
Hysteria; (2) intestinal catarrh; (3) pregnancy; (4) malignant 
degeneration of a tumor; (5) fibrocystic tumors; (6) suppurative 
inflammation of the adnexa. To these Schaeffer would add 
any acute or subacute inflammation of the pelvic viscera, a 
very hard or fully matured tumor, an excessively large growth, 
a submucous growth which is pedunculated, enfeebled heart 
action, and acute nephritis. 

177. Faradic. — The current of induction has a primary 
and a secondary current. One pole may be applied in the 
vagina or the uterus; the other, over the abdomen. Apostoli 
advised a bipolar electrode in which the negative and positive 
poles were placed in the same electrode, with a band of non- 
conducting material between them. In this way the current 
of electricity was limited to a greater extent to the tissues de- 
sired to be affected. This method of procedure was less painful. 
The primary current is one of quantity; the secondary one of 
tension. The latter is dependent upon the length and fineness 



( 



ELECTRICITY. 



115 



of the wire. The current of tension is effective in subduing 
pain, such as ovaralgia, abdominal pain in hysteric women, 
vaginismus, and pain from pelvic inflammation. It proves 
to be an emmenagog. It may be applied three times weekly, 
or even daily, each sitting lasting from ten to thirty minutes. 
The electrode is first introduced; the current is then opened 
slowly, and gradually closed before the electrode is removed. 
This is necessary in order to prevent severe pain. 

178. Sinusoidal. — Apostoli employed a current introduced 
by d'Arsonval, known as the sinusoidal. The patient is placed 
upon an insulated couch beneath Avhich is a large coil of wire 
through which a current of 450 milliamperes is passed. The 




— Faradic Battery. 



patient is enveloped in an electric atmosphere in which the 
effects will depend upon the number of alternations in a second, 
the degree of electromotor force, and the quantity of current. 
It acts more particularly upon the muscular structures without 
the occurrence of pain or disagreeable sensation. Its employ- 
ment modifies nutrition by an increased absorption of oxygen 
and the greater elimination of . carbonic acid. The current 
exerts a marked analgesic effect, which frequently induces 
the disappearance of painful symptoms. It is consequently 
of benefit in dysmenorrhea, but has displayed its beneficial 
effects to the greatest extent in the treatment of peri-uterine 



116 GYNECOLOGY. 

inflammations and pelvic exudates, in the resorption of which 
it is one of the most effective means at our disposal. 

179. Rontgenic. — This term is applied to peculiar rays of 
light which are engendered by light under electric excitement, 
being transmitted through tubes of very high vacuum. The 
discoverer of this phenomenon, Professor Rontgen, of Wurz- 
burg, designated these rays as the rt:-rays. The influence of 
the discovery of a procedure capable of transillumination of 
the structures of the body can hardly be estimated. The 
^-rays have proved both diagnostic and therapeutic. They 





Fig. go. — Bipolar Uterine Electrode. 
+ . Positive pole. - — ■. Negative pole. 

can be generated through the employment of the static machine ; 
the induction coil, batteries, and the electric -lighting main. 
The essential portions of the apparatus are the vacuum tube 
and fluorescent screen. The latter consists of a lightly con- 
structed tight box, somewhat similar in shape to the stereo- 
scope. The small end has an aperture which is made to flt 
tightly over the eyes and bridge of the nose. The inner sur- 
face of the broad end is covered with a uniform layer of fine 
crystals of a fluorescent material, generally barium platino- 
cyanid, or calcium tungstate. Not only is the operator able 



Fig. 91. — Vaginal Electrode — Bipolar. 

to inspect the internal structures of the body, but he is also 
able to record what he sees upon a sensitive photographic 
plate for the benefit of others. 

The employment of the procedure has afforded information 
of value in the diagnosis of obscure cases, notably in pregnancy 
and ectopic gestation. The beneficial influence of the rays 
in the treatment of superficial malignant and tubercular con- 
ditions suggests the hope that it may be equally effective in 
arresting the ravages of these disorders when they involve 
the deeper structures. The rays are found to exert a more 



ELECTRICITY. 117 

destructive action upon the less resisting malignant cells than 
upon the healthy tissues. If subsequent investigation shall 
demonstrate the correctness of this view, which now seems 
probable, the operator who does not follow his radical opera- 
tion with the employment of the Rontgen rays to destroy in- 
fectious germ-cells which have possibly lodged in the neighbor- 
ing lymphatic spaces and vessels will fail of doing full justice 
to the interests of his patient. In carcinoma of the cervix 
the depth of the tissues involved from the surface renders the 
application more difficult, and requires special care to pro- 
tect the superficial structures from burns which would delay 
and arrest the necessary treatment. 

Protection from this undesirable result is best afforded by 
moulding to the surface a sheet of blotting-paper, covered 
with four layers of tinfoil. The shield should extend some 
five centimeters in each direction. For treatment of uterine 
cancer a lead-lined rubber speculum may be employed to ex- 
pose the surface. Painful symptoms and obscure neuralgias 
are frequently greatly benefited when the painful part is sub- 
jected to the x-rays. This fact seems of portentous significance 
in the field of gynecology. 

1 80. Finsen Light. — The Finsen light consists of the ultra- 
violet rays, which are invisible to our vision and are capable 
of refraction and concentration. They exist largely in sun- 
light, but may be artificially produced from the arc light. Glass 
is a non-conductor to these rays, therefore it is necessary to 
construct a plate or disc of quartz, or, still better, of trans- 
parent rock salt. The Finsen light differs from the Rontgen 
rays in being very destructive to bacterial life, while the latter 
rather, if it has any effect, facilitates bacterial gro\\i:h. The 
application of the Finsen light must, under present conditions, 
have a limited application in gynecology, because it causes 
an anemia of the tissues upon which it is purposed to exert its 
influence. 

181. Electrocautery and Light. — The employment of elec- 
tricity as a means for the production of heat for cautery pur- 
poses has Avon a well-recognized place through the work of 
Byrne with the galvanocautery and later its ingenious applica- 
tion by Skene and Downes to electrothermic hemostasis. 

The power can be secured by batteries of large size, by 
storage cells, or, better, from the street main through a trans- 
former. Dr. Downes has modified and improved the instru- 
ments devised by Skene. He applies a special form of angio- 
tribe to the broad ligaments, which, when raised to a dull red 
heat, divides and cooks the tissues, thus rendering ligatures 
unnecessary. 



118 GYNECOLOGY. 

The great advantage of this procedure is in hysterectomy 
for cancer of the uterus, as it enables the removal of a large 
amount of possibly infected tissue. The malignant cells which 
have been carried into the parametrium are supposedly less 
resistant to the effects of heat than healthy tissue. There- 
fore, it seems reasonable to infer that some of these are de- 
stroyed by the electrothermic measures which would other- 
wise survive to cause relapse if other methods of operating 
had been employed. 

The same class of batteries enumerated for cautery pur- 
poses may also be employed for electric lights. The electric 
light is especially useful in inspecting the urethra, bladder, 
ureters, and rectum. The electric light in a cystoscope can 
be introduced through the urethra and the entire cavity of 
the bladder exposed, the orifices of the ureters recognized and 
any changes in the structure of the bladder are readily observed. 
The instrument may be employed to irrigate the bladder by 
closing its end; the bladder can be distended with air or gas, 
thus determining the capacity of the organ. Loss of structure, 
thickening, growths, and other changes in its walls are also 
perceived. It can also be employed for local medication and 
for catheterization of the ureters. The electric light can be 
employed to illuminate the rectum through long or short proc- 
toscopes, the vagina by an attachment to a speculum, and 
even to look into the uterus, but as the latter canal has to be 
previously dilated, the instances are rare when its illumination 
will be of practical service. 



EMBRYOLOGY AND ANATOMY OF THE GENITO-URINARY 
ORGANS OF THE WOMAN. 

182. Development of the Genito-urinary Organs. — Some know- 
ledge of the origin and processes of development of the organs 
is necessary to a proper understanding of the conditions in 
which they have failed to attain the normal. The embryonic 
period may be divided into five periods or stages. 

The -first period extends to the eighth week. Up to the fifth 
week from fecundation there is developed no sexual indication. 
The primordial kidney, the Wolffian body, the duct of Miiller, 
and the Wolffian duct, from which the genital organs are to be 
developed, are found one upon each side of the median line. 
A cloaca is situated at the site of the future vulva, into which 
the urachus and intestine open. From the external surface 
of each Wolffian body a structure known as the genital gland 
develops, which subsequently becomes either the testicle or 



EMBRYOLOGY. 



119 



ovary. Simultaneously, the cloaca is divided by a projection, 
the genital eminence or tubercle, which is marked by the gen- 
ital furrow or groove. 
Their appearance at 
the eighth week af- 
fords no clue as to 
the probable sex. 

The Second Period 
(Eighth to the Twelfth 
Week).— The Miiller- 
ian ducts coalesce, and 
the septum disappears 
in their lower two- 
thirds, w^hile the in- 
sertion of the round 
ligament indicates the 
point of division be- 
tween the tube and 
the uterus. The clo- 
aca, by the develop- 
ment of the perineum, 
is divided into two 
portions — the urogen- 
ital sinus and the 
anus. 

The third period 
(twelfth to twentieth 
week) witnesses the 
fusion of the uterine 
horns ; the appearance 
of the arbor vit^ in the 
cavity of the uterus; 
the formation of the 
cervix ; enlargement of 
the perineum ; and de- 
velopment of the va- 
gina, which opens into 
the urogenital sinus 
and forms the vesti- 
bule of the vagina, in 
which the hymen ap- 
pears. The genital tu- 
bercle, which has been 
large, is reduced to 
the proportions of the 
become the nymphas. 




18 19 iS 



Fig: 



92. — Human Embryo at End of Thirty-five 
Days. — (Coste.) 
Tongue. 2. Aortic Bulb. 3. First permanent 
aortic arch. 4. Second aortic arch. 5. Third 
aortic arch, or ductus BotaUi. 6. The two 
filaments to the right and left of this figure 
are the pulmonary arteries. 7. The trunk of 
the superior vena cava and the right azygos 
vein. 8. The common venous sinus of the 
heart. 9. Left auricle of the heart. 10. 
Right ventricle. 11. Left ventricle. 12. 
Lungs. 13. Stomach. 14. Left omphalo- 
mesenteric vein. 15. Wolffian body. 16. 
Right omphalo-mesenteric vein. 17. Intes- 
tine. 18, 18. Umbilical arteries. 19. Um- 
bilical vein. 



clitoris, and the edges of the genital fissure 



120 



GYNECOLOGY. 



The fourth period extends from the twentieth week to the 
end of fetal life. During this period the fundus of the uterus 




Fig. 93. — Coalescence of Miiller's Duct. 

increases in size ; folds form in the vagina, as well as in the cervix, 
and the labia majora become fuller and more rounded. 
.'< The fifth period comprises the time from birth until puberty. 
The uterus increases in size and thickness; the uterine mucous 





Progress of Development of the Genitalia. 



Fig. 94. — All. Allantois. 
R. Rectum. M. Miil- 
ler's duct. X. In- 
dentation of the skin 
which forms the 
anus. — {Schroder.) 



Fig. 95. — CI. Cloaca. 
B. Bladder. R. 
Rectum. V. Va- 
gina. — {Schroder.) 



Fig. 96. — Su. Urogenital 
sinus. R. Rectum, 
separated from the 
former by the peri- 
neum. B. Bladder. 
V. Vagina, u. Ure- 
thra. — {Schroder.) 



membrane, which up to the sixth year is folded like that of the 
cervix, becomes smooth. The vagina is elongated and the 
vulva is larger and more rounded. 



ANATOMY. 121 

183. Division of the Genitalia. — The special generative 
organs of the woman are situated in the pelvis in close associa- 
tion with the bladder and urethra, the rectum, and the anus. 
The female genitalia are divided into two classes: The external 
and internal organs, the former of which with the vagina form 
the organs of copulation, and the latter the reproductive organs 
proper. 

184. The external genital organs are, enumerated from 
before backward, the mons veneris, the labia majora, the labia 
minora, the clitoris, the vestibule, perforated by the meatus 
urethrse externus, the orifice of the vagina, surrounded in the 
virgin by the hymen, the fourchet, the fossa navicularis, and 
the perineum, situated between the vulva and the anus. The 
external genitalia are also called the vulva, pudendum, or 
cunnus; the cleft between the labia majora is known as the 
rima pudendum. 

185. The mons veneris is a cushion of fat situated over 
the pubes, covered with thick skin which is abundantly sup- 
plied with hair. The hair protects the vulva from the per- 
spiration of the body. When the nude woman is erect, the 
mons veneris is the only portion of the genitalia visible. 

186. The labia majora are skin folds which unite in front 
of the mons veneris. Posteriorly they thin off and terminate 
about one and one-half inches in front of the anus. Externally 
they are covered with short, crisp hair, which is continuous 
with that of the mons veneris. They are profusely supplied 
with sebaceous and sudoriferous glands. Their internal sur- 
faces lie in contact and present a smooth, moist surface which 
resembles mucous membrane. The apposition of the labia 
majora, slightly separated by the labia minora and clitoris, 
forms the cleft of the vulva, the rima pudendum. Each labium 
contains a sac-like structure called the dartoid. This is anal- 
ogous to a similar structure in the male scrotum. The round 
ligament, and in the fetus an open canal, called the canal of 
Nuck, terminates in this dartoid sac. Occasionally the latter 
remains open in the woman and permits the formation of a 
hydrocele. In fat subjects these folds contain a large quantity 
of adipose cellular tissue. 

187. The labia minora are situated between the labia majora, 
slightly projecting beyond their level, and are much more pro- 
minent anteriorly. Upon wide separation they are seen to 
be continuous with the fourchet, and form the posterior com- 
missure. Anteriorly they bifurcate and form two folds, an 
anterior, which passes in front of the clitoris and forms its 
prepuce or hood. The second passes behind the glans clitoris 
and forms the frenulum. The labia minora, also called the 



122 



GYNECOLOGY. 



nymphag, have a smoother, but shghtly roughened surface with 
free convex, sometimes notched, borders. Frequently small 
openings or perforations will be seen. The size of the nymphae 
varies greatly, according to the age and race. They project 
considerably beyond the vulva in the young child, but, owing 
to the increase in size of the labia majora as puberty approaches, 
they are rendered less apparent. In the Bushwomen the 



.«s^^" 



yi%zi£kkr^,^ 




Fig. 97. — Virgin Vulva; Labia not Separated. — (From Deaver.) 



labia minora frequently become so long that they reach to 
the knees, and are then spoken of as the Hottentot apron. 
The skin is covered with a stratified pavement epithelium, 
similar to that of the true epidermis. They are plentifully 
supplied with sebaceous glands, especially at the base of the 
folds, where they form a crowded layer upon the inner surface. 



ANATOMY. 



123 



In the brunette the pigment deposit is frequently so great as 
,to make them noticeably dark. The skin folds contain a small 
amount of connective tissue. During the act of coition the 
labia minora draw the glans clitoris against the male organ. 

1 88. The clitoris, as in the male, is an erectile organ having 
its origin from the posterior surface of the ischiopubic rami, 
arising on either side as a cms clitoridis or corpus cavernosum. 
These unite to form one body in front of the symphysis. The 
organ is secured to the symphysis by the action of the sus- 




Fie. 



-Virgin Vulva; Labia Separated, Showing the Hymen Unruptured. 
— {From Deaver.) 



pensory ligament, and its circulation is influenced by the ischio- 
cavernosus muscle, in which respect, therefore, it resembles 
the penis. The corpora cavernosa are enveloped by a fibrous 
investment and separated by a median septum of cavernous 
tissue composed of fine trabeculse, in which the muscular ele- 
ments predominate. The free extremity of the clitoris is situated 
at the anterior part of the vulva, about one-half inch behind 
the anterior extremities of the labia majora. The organ is 
surmounted by a median tubercle known as the glans clitoridis. 
The glans is more or less covered by the prepuce, which is formed 



124 



GYNECOLOGY. 



by the anterior folds of the labia minora or nymphae. The 
glans is imperforate and is generally but slightly developed.^ 
When it appears enlarged the other parts of the vulva will 
generally be found small and ill developed. 

189. The vestibule is, by some anatomists, described as 
the entire space between the labia minora, which, prior to the 
rupture of the hymen, includes its external surface; but as 
this portion largely disappears after successful coition, and 
completely after parturition, it seems better to confine this term 
to the portion ordinarily called by that name, which is the 
space bounded on each side by the labia minora, and posteriorly 





Fig. 99. — Hymen Crescens. 



Fi< 



-Hymen Annularis. 



by the anterior border of the vagina. This triangular space 
has the glans clitoridis at its apex. At its center near the 
posterior border is a rounded, pouting orifice — the meatus 
urethrae externus. The openings of the ducts of two clusters 
of large mucous follicles are also found in this situation. One 
of these groups lies immediately behind the clitoris, and when 
the ducts become occluded a cyst is formed. The other group 
is near the sides of the meatus. Mucus is secreted very freely 
by these follicles under any persistent local irritation. In 
the virgin a grooved ridge is found which, according to Pozzi, 
represents the corpus spongiosum of the male and is known 



ANATOMY 



125 



as the vestibular band. The orifice of the meatus urethra 
is situated behind the chtoris in the posterior part of the vesti- 
bule and about one inch in front of the fourchet. It ordi- 
narily presents a longitudinal or starred slit, the borders of which 
are shghtly notched and projecting. Occasionally its mucous 
membrane bulges, forming a ring-like margin. Within the 
elevated margins of the meatus and slightly posterior to its 
center is found a minute opening, on each side, which usually 
is not easilv detected in healthv subjects ; but following gonorrhea 





Fio;. loi. — Hvmen Serratus. 



Fis:. 1 02. — Hvmen Infundibularis. 



or leukorrhea they may be readily recognized. These openings 
are the orifices of Skene's ducts, which are parallel to the ure- 
thra and about two centimeters in length. They should be 
recognized, as they are sometimes so large that a catheter 
may enter one of the canals instead of the orifice of the urethra. 
190. The hymen is a thin membrane acting as a sort of dia- 
phragm between the internal genital parts on the one side, 
and the external parts and orifice of the urethra on the other, 
which is revealed by separation of the labia minora (Fig. 98). 
Its external surface resembles the structure of the latter, while 
the internal presents not infrequently the rugae of the vagina. 
When the labia are not forcibly separated, the hymen appears 
as a vertical slit with its lateral edges in contact. With the 



126 



GYNECOLOGY. 



labia held apart, however, the opening is usually crescentic 
with its concave margin anterior (Fig. 99). Sometimes it is 
annular with a central opening (Fig. 100). The h3^men may 
present a variety of forms and openings, such as the labial 
form, in which the lateral folds may be mistaken for the labia 
minora; the linguaformis, which presents a tongue-shaped 
projection posteriorly, and the falciform, which has a some- 
what long and wide orifice. The free edge of the hymen may 
be smooth, denticulated, or serrated (Fig. loi). Its structure 
may be thick and fleshy, and present irregular folds resembling 
fimbrise. The infundibular form (Fig. 102) presents a funnel- 
shaped appearance with the margins looking downward and 





Fig. 103. — Hymen Biseptus. 



Fig. 104. — Hymen Cribriformis. 



backward. There may be two openings, the septus or biseptus 
(Fig. 103), or a number of openings, as the cribriform (Fig. 104). 
The mem^brane is usually thin and easily torn, but occasionally 
it is so firm that it withstands the most strenuous efforts at 
coition, and, therefore, will require incision before the sexual 
act can be accomplished. The hymen usually ruptures during 
the first coition, and occasionally its tear is followed by pro- 
fuse and often dangerous bleeding (Fig. 105). The greater 
portion of the hymen is destroyed during the process of par- 
turition, the remainder shrinking together to form small masses 



ANATOMY. 



127 



at the vaginal outlet. These masses are known as the carun- 
culas myrtiformes. The number, form, and situation of these 
caruncles vary extremely. Generally there are three. One 
is situated at the posterior part, the others at the sides of the 
entrance to the vagina. Both surfaces of the hymen are covered 
with pavement epithelium. The hymen guards the entrance 
to the vagina. 

191. The fourchet is a continuation backward of the labia 
minora in the form of a thin fold, and is rendered prominent 
by the separation of the vulva. Between this fold and the 
hymen is a boat-shaped depression called the fossa navicularis. 
Between the fourchet and the anal 

opening is an intervening space cov- 
ered with integument some four cen- 
timeters in length, which is called 
the perineum. 

192. The muscles of the perineum 
are exposed by the removal of the 
skin, the superficial fascia, and a 
layer of the deep fascia. The mus- 
cles thus mapped out are: The erec- 
tor cUtoridis; the bulbocavernosus and 
the transversus perinei, paired mus- 
cles ; and the sphincter am and levator 
am, which are single. The erector 
cUtoridis arises from the anterior 
margin of the rami of the pubes and 
ischium and is inserted by two ten- 
dinous expansions, one above the 
junction of the crura into the bod}^ 
of the clitoris, and the other below 
and in front. The bidbocavernosi 
muscles arise from the tendinous 
raphag and anterior aponeurosis of 
the perineum, and are separated by 
the vagina, around which they 

course, to be inserted by a thin slit into the crus of each side 
in front of the erector cUtoridis. The outer fibers of the mus- 
cle wind inward beneath the erector muscle to reach the upper 
part of the bulb near its isthmus. A portion of the median 
fibers are apparently derived from the sphincter and pass up- 
ward to the clitoris, over the pubes, and are lost in the super- 
ficial fascia. Other fibers form a delicate muscular arch in 
front of the body of the clitoris. The action of the muscle is 
to compress the bulb of the vagina and to some degree act as 
a sphincter of the vagina, though Savage assigns the latter 




Fig;. 10^. 



-Laceration of the 
Hvmen. 



128 



GYNECOLOGY. 



function to a portion of the levator ant. The relation of a 
portion of the fibers to the sphincter ani produces a figure- 
of-8 action upon the two orifices, which it is important to re- 
member in operations upon the sphincter. The transversus 
perinei muscles arise one on each side from the tuberosity of 
the ischium and are attached to the anterior aponeurosis of 
the perineal septum, the perineal body, and the skin of the 
perineum in front of the anus. The sphincter ani arises from 
the tip of the coccyx and is attached in front to the tendinous 




Fig. 1 06. — Muscles of the Female Perineum.— (Z^^az^g-r.) 



raphce of the perineum where it meets the fibers of the bulbo- 
cavernosi. Its fibers, closely attached to the skin, decussate 
in front of the anus, while some fibers appear to pass com- 
pletely around it. The muscle is pierced by radiating fibers 
from the longitudinal muscular coat of the rectum and is in 
close relation with the levator ani and internal sphincter. This 
muscle forms the external sphincter and is voluntary in its 
action. The levator ani is the principal muscle of the pelvic 



ANATOMY. . 129 

floor. It arises from the back of the body and horizontal 
ramus of the pubes, the pelvic fascia (white line), and the spine 
of the ischium. From its origin the muscle sweeps downward 
and inward and is attached in the middle line from before 
backward as follows: To the vagina, to the rectum, to its fellow 
of the opposite side, and, finally, to the tip of the coccyx. The 
pubic fibers blend with the posterior half of the upper border 
of the sphincter vagince. This muscle is more readily exposed 
from above. 

The vulvovaginal gland K'ith the bulb of the vestibule are ex- 
posed in the dissection already described. The former is a 
racemose gland, of which there is one situated on either side 
of the vagina and posterior to its orifice. It is analogous to 
Cowper's gland in the male. It is also known as the vulvar 
gland of Bartholin, or, according to Hugier, the vulvovaginal 
gland. It is about the size of an almond, but varies in different 
individuals and even upon the two sides. Occasionally glan- 
dular nodules are seen, which seem to be detached from the 
gland and scattered in the surrounding muscle. Within, the 
gland is in close relation with the vagina, to which it is adherent 
by tense cellular tissue, while externally it lies beneath the 
bulbocavernosus muscle. Its excretory duct, about one centi- 
meter long, is directed from below upward and from without 
inward and opens in the angle between the hymen and the wall 
of the vulva. When the hymen has disappeared, its orifice 
is found in the corresponding angle between the carunculae 
myrtiformes and the wall of the vulva. It is usually difficult 
to detect, but sometimes presents an orifice which will admit 
a probe. This gland furnishes the secretion which is manifest 
under the infiuence of sexual excitement or during coition. 
The bulb of the vestibule is a venous mass which is situated 
along each side of the vagina and the vestibule. It is related 
within to the vagina, vestibule, and urethra, and is covered 
externally by the bulbocavernosus muscle. The bulbs unite 
beneath the clitoris by a venous connection, the pars inter- 
media. Kobelt says the injected bulb is nearly four centi- 
meters long, one centimeter wide, and from nine-tenths to one 
and one-tenth centimeters thick. Its external surface is convex, 
its internal surface concave. The bulb is a part of the erectile 
tissue of the female genital organs and is analogous to the cor- 
pus spongiosum in the male. 

193. The perineal fascia or the fascia of the pelvic floor 
consists of the following: 

1. The superficial fascia. 

2. A deep layer of the superficial fascia. 

3. The triangular ligament, composed of two layers. 
9 



130 • GYNECOLOGY. 

The superficial fascia is a continuation of the general fascia 
of the body. It consists of two layers, an outer, more or less 
loaded with fat, which is continuous with the same layer over 
the buttocks, thighs, and abdomen. An inner, more resisting 
membranous investment descends from the abdomen, narrowed 
to the width of the pubes, but spreading out so as to envelope 
the anterior perineal triangle at its base — the perineal septum. 
The abdominal portion of the fascia is firmly adherent to Pou- 
part's ligament; the perineal portion to the outer margin of 
the ischiopubic rami and the inferior margins of the septum, 
while the pubic portion is attached along a curved line of the 
bone, which indicates the origin of muscles of the anterior part 
of the thigh. 

A tubular prolongation extends backward from the margin 
of the external inguinal ring on each side of the vagina, nearly 
to the posterior vulvar commissure, and is known as the pu- 
dendal sac. With its fellow of the opposite side, when envel- 
oped with their cutaneous coverings, the two sacs form the 
labia majora. The pudendal sac contains more or less fatty 
tissue and the terminal fibers of the round ligament of the uterus 
are also lost in it. The sac may be the seat of hydrocele from 
a patulous canal of Nuck, or a hernia may develop by a descent 
of a section of gut or omentum through this canal. The in- 
jection of air into the sac gives a similar appearance to that 
induced by hernia. The fascia passes around the transverse 
perineal muscles to form the anterior layer of the triangular 
ligament. This union forms the ischioperineal ligament — a 
very firm aponeurotic band attached to the outer ends of the 
rami of the ischii in front of their tuberosities. 

The deep fascia, or triangular ligament, has two layers — 
an anterior, or superficial, and a posterior, or deep. The super- 
ficial is attached to the rami of the pubes and ischium, and 
to the so-called transverse hgament of the pelvis, which lies 
immediately behind the subpubic ligament, from which it is 
separated by an opening for the dorsal vein of the clitoris. 

Behind it is united with the superficial, as well as with 
the deep, layer of the pelvic fascia. The deep layer is also 
attached to the rami of the pubes and ischium, and joins the 
obturator fascia covering the lower portion of the anterior 
surface of the levator ani muscle. In front it is continuous 
with the vesicorectal fascia; and behind, with the dense anal 
fascia which covers the under surface of the levator ani muscle. 

The junction of the three layers of fascia behind forms the 
ischioperineal ligament, which marks the boundary-line be- 
tween the urogenital and anal regions. 

The upper surface of the levator ani muscle is covered by a 



ANATOMY. 131 

fascia called the pelvic, which is a continuation of the iliac. 
The pelvic fascia is attached to the iliac portion of the ilio- 
pectineal line and to an oblique line upon the posterior surface 
of the pubic bone, from above and within the obturator foramen, 
to just below the symphysis. It covers the inner surfaces of 
the ilium and ischium about halfway down the pelvic wall until 
it reaches the so-called tendinous arch, which extends from the 
spine of the ischium to the pubic bone and below the obturator 
canal. This portion covers the obturator muscle, and is known 
as the obturator fascia. A thinner prolongation extends back- 
ward, and is known as the pyriform fascia. . 

The pelvic fascia splits into two layers at the tendinous 
arch — an upper, called the vesicorectal fascia, which extends 
over the levator ani muscle, and a lower layer, which follows 
the obturator internus muscle to the inner edge of the ischio- 
pubic branches, and retains the name of obturator fascia. 
Below the insertion of the levator ani muscle is given off an 
investment, which is called the anal fascia. In conjunction 
with the portion of obturator fascia below the tendinous arch 
it serves as a lining for the ischiorectal fossa. 

The vesicorectal fascia, from its insertion upon the pelvic 
wall, passes inward and downw^ard and covers the upper sur- 
face of the levator ani to the base of the bladder, the vagina, 
and the rectum. In front, near the middle line, a thicker part 
of this fascia forms the anterior true ligaments of the bladder, 
or pubovesical ligaments. 

A ligament of the rectum arises from the ischial spine and 
is attached to the side of the rectum. It presents a double 
layer of fascia with intervening loose connective tissue, and 
permits a sliding movement of one part over another. 

A study of the relations of the pelvic structures to the layers 
of the fascia results in the following, according to Hart and 
Barbour : 

( Superficial hemorrhoidal vessels and 
Between the skin and superficial fascia : ^ nerves. 

i Superficial perineal artery and nerve. 
Transversus perinei. 
Bulbocavernosus. 
Erector clitoridis. 

Between the deep layer of the super- ] Transverse perineal blood-vessels and 
ficial fascia and the anterior layer I nerves, 
of the triangular ligament: ] Venous plexuses. 

Bulbs of the vagina. 
Pudendal sacs. 

Dorsal artery and vein of clitoris. 
( Compressor urethras. 
Between the layers of the triangular ' Vagina, in part, 
ligament: t Urethra, in part. 

V Pudic vessels and nerves. 



132 



GYNECOLOGY. 



194. Pelvic Diaphragm. — The structures already described 
as the soft parts, consisting of the pelvic fascia and the muscular 
structures, constitute the pelvic diaphragm, of which the most 
important structure is the levator ani (Fig. 107). 

The origin and insertion of this muscle have been given. 
It is generally described as two muscles, the levator ani and 
the coccygeus, but as there is practically no separation, this 
seems an unnecessary distinction. Savage divides it into 
three, the pubococcygeus, the obturator coccygeus, and the 





Fig. 107. — The Under Surface of the Levator Ani Muscle. — (Deaver.) 



ischiococcygeus, but this division seems inappropriate when 
we recognize the fact that none of the muscular fibers arising 
from the pubes reach the coccyx. The anterior portion of 
the muscle is covered by the muscles and structures of the 
external genitalia. The posterior portion is enveloped with 
the fascia and covered with the following additional layers: 
the skin; the adipose tissue filling up the ischiorectal fossa, 
and known as the ischiorectal fat. The boundaries of this 
irregular triangular space are the levator ani, covered by the 



ANATOMY. 133 

anal fascia on the inner side, and the obturator internus muscle, 
covered by the obturator fascia on the outer side. The lower 
surface is bounded by the anterior edge of the gluteus maximus 
muscle and the greater sacrosciatic ligament behind, the trans- 
versus perinei muscle in front, and the sphincter ani upon the 
inner side. The apex of the triangle is at the spine of the isch- 
ium. Behind, the two fossa communicate by the loose adipose 
tissue back of the rectum, and also by the pelvic fascia. In 
front, the fossa is limited by the line of junction of the super- 
ficial and the deep fasciae. 

The posterior fibers of the levator ani pass behind the rectum 
and are continuous with those of the opposite side. Other 
fibers are attached to the tip and side of the coccyx. 

Action. — The pelvic diaphragm strengthens the pelvic floor, 
and, in association with its two enveloping layers of fascia, 
forms a strong support for the uterus and bladder. Obser- 
vation of the movements of the floor, with the employment 
of Sims' speculum, reveals a rhythmic movement synchronous 
with respiration. The anterior pelvic segment goes down- 
ward and backward during inspiration and upward and for- 
ward with expiration. The muscle serves to raise up the rectum 
during defecation and draws the anus toward the symphysis. 
The fibers between the rectum and vagina influence the size 
of the vaginal orifice. 

195. Perforations (Fig. 108). — The pelvic fioor is perforated 
by three slit -like openings, two of which, the vagina and ure- 
thra, have axes parallel with the conjugate diameter of the 
brim. The rectum for a part of its course is similar, but turns 
backward at the lower part, where it is separated from the 
vagina by the perineal body. The axis of the anus is at right 
angles with the plane of the brim. Transverse section of the 
pelvis through the middle and lower third of the vagina shows 
it folded in the shape of a letter H, with a short lateral and 
a long transverse bar. The urethra presents a transverse slit, 
and the rectum an antero-posterior fold. 

196. Internal Genitalia. — The internal genitalia are: The 
vagina, the uterus, the Fallopian tubes, the ovaries, and the 
parovarium. 

197. The vagina is a musculomembranous canal lying be- 
tween the bladder and the rectum, and extending from the 
vulva to the uterus. It is fixed below by its attachments to 
the pelvic floor, and above surrounds the cervix, with which 
it is continuous. The direction of the A^agina varies with the 
position and the condition of the adjoining organs — the bladder 
and the rectum. In the erect position it forms an angle of 
about 60 degrees with the horizon, and is parallel with the 



134 



GYNECOLOGY. 



conjugate diameter of the brim of the pelvis (Fig. 109). Its 
walls are irregularly triangular, with the widest point at the 
upper part, where the uterus enters, which in the nullipara 
measures 3 or 4 cm. ; in multipara, 6 or 7 cm. The anterior 
wall is the shorter, 5 cm. long, while the posterior is 7.5 cm. 
In the normal condition and with the bladder empty, the cervix 
enters the vagina at a right angle. This angle is rendered 
more obtuse by distention of the bladder or by an accumulation 
of feces within the rectum. The vagina is attached to the 
cervix about 1.5 cmx. from the external os, and forms with 
the cervix a sulcus front and back. The former is known as 




Fig. 108. — The Upper Surface of the Levator Ani Muscle. — (Deaver.) 



the anterior, and the latter as the posterior, vaginal fornix. 
The anterior and posterior vaginal walls lie in contact, and, 
upon mesial section, present a slit with a slightly convex line 
directed anteriorly. Transverse section is represented by an 
H -shaped slit, the lateral arms of which are convex upon their 
inner aspect with the horizontal limb bending slightly ante- 
rior. 

The vagina in multiparas is capable of wide distention, and 
is of quite variable shape. The anterior vaginal wall is united 
with the posterior surface of the bladder by loose connective 
tissue, which permits its dissection, though separation rarely 



ANATOMY. 



135 



occurs. The urethra is more intimately associated with this 
wall; however, it presents no difficulty in dissection. 

The mucous membrane of the anterior wall is thrown into 
numerous folds or projections, called the rugae, which are more 




Fig. 109. — A Mesial Section; the Body Erect. — (Deaver.) 



marked toward the vulva and decrease in size as the upper 
end of the canal is approached. There are also temporary 
foldings, which disappear as the vagina is distended. The 



136 



GYNECOLOGY. 



rugae consist of a series of transverse ridges, which extend 
obliquely upward and outward from the longitudinal stem, 
known as the anterior column. 




The transverse projections are composed of secondary 
ridges, covered with papillae. The anterior column generally 
begins behind the meatus and disappears in the upper third of 



ANATOMY. 



137 



the vagina; occasionally, its lower portion is divided into two 
parts by a longitudinal groove, the opposite halves of which 
subsequently unite. The rugse are especially marked in young 
children and virgins, and largely disappear in the multipara. 
The posterior wall also presents a column with transverse rugae, 
but less marked than upon the anterior. 






Fig. III. — Arteries and Nerves of the Female Perineum. — {Savage.) 
Internal pudic. 2, 3. Inferior hemorrhoidal. 4. Transverse perineal. 5. 
Superficial perineal or vulvar. 8. Artery of the bulb. 7. Profunda 
branch to the clitoris. 9. Dorsal artery to the clitoris. 10. Inferior 
hemorrhoidal nerve to sphincter and lower rectum. 11. Posterior super- 
ficial. 14. Anterior superficial branches to the vulva. 13. Trunk of the 
nerve. 12. Posterior muscular. 15. Anastomotic. 16. Pudendal branch 
of (17) the smaller sciatic. 18. 18. Continuation of pudic ending in nervous 
sheath for the clitoris. 19. Outer terminal branch of the ilio-inguinal 
nerve. A. Anus. M. Urinary meatus. C. Clitoris. L. Greater sacro- 
sciatic ligament. V. Vagina. O. Coccyx. A. Gluteus maximus. b. 
Superficial sphincter, c. Anterior edge of ischio-coccygeus. d. Superficial 
transverse muscle. e. Bulbocavernosus muscle. /. Slip of anterior 
aponeurosis of perineal septum, g. Upper portion of erector clitoridis 
muscle. /. Adductor magnus. k. Gracilis muscle. T. Nerve-fibrils to 
integument. 



The Upper part of the vagina presents, when distended, 
a dome-like appearance, in which the posterior fornix is twice 
the depth of the anterior, ow4ng to the higher attachment 
upon the cervix. The lateral fornices have no especial depth, 
and only connect the anterior and posterior. As the patient 



13S 



GYNECOLOGY. 




advances in years the vaginal walls atrophy and the rugae 
gradually disappear. 

The wall of the vagina consists of three layers: an external 
connective-tissue layer; a middle, of unstriped muscular fiber; 
and an inner, of mucous membrane. The exterior layer binds 
the uterus to the surrounding structures and supports the 
plexus of vessels and lymphatics. The muscle structure con- 
sists of longitudinal and circular fibers, 
intricately interlaced. A bundle of 
striated muscle-fibers is described by 
Luschka as surrounding the lower end 
of the vagina as well as the urethral 
orifice, which he calls the sphincter 
vaginae. 

The mucous membrane, which ex- 
tends from the free edge of the hymen 
to the cervix, over which it is reflected 
to the external os, varies in thickness 
from I to I J mm. It is of a rosy-red 
color, but may vary from a light pink 
to a dark purple or slate-color. The 
latter color is especially characteristic 
of pregnancy. The mucous membrane 
is closely attached to the subjacent 
muscular layer, and is thrown into the 
already mentioned rug^. The surface 
is covered with numerous papillae, which 
are greatly increased in size by preg- 
nancy. 

The mucous surfaces are covered 
with an acid mucus, which is also 
markedly increased during pregnancy. 
The thickness of the vaginal wall is 
greater below, where it is about one 
centimeter, while at the upper part it 
is not over five millimeters. The dif- 
ference in thickness is due to the varia- 
tion in the muscular wall. 

A microscopic section of the vaginal 
wall presents an external layer of fibrous tissue, enveloping 
large veins, which belong to the vaginal venous plexus. These 
are surrounded by bundles of smooth muscle-fibers suggestive of 
erectile structure. Accompanying the veins are large lymph- 
atics, some of which are distended to form sinuses. A middle 
or muscular layer is also present, in which the outer fibers seem 
divided transversely ; the inner ones being longitudinal. 




u 



Wall 



Fig. 112. — Anterior 

of Vagina Showing 
Columnae Rugarum. — 
(By ford, after Savage.) 

I, 2. Anterior columns of 
the vagina. U. Ure- 
thral orifice. M. Cer- 
vix. 



ANATOMY. 139 

The mucous membrane consists of a firm basement mem- 
brane in which are numerous elastic fibers. It is covered by 
several layers of stratified pavement epithelium (Fig. 113). 
In addition to the large folds into which the mucosa is thrown, 
it forms secondary elevations, or papilla, in each of which 
is a capillary loop. These loops are single near the fornix, 
but present a more complicated network near the introitus. 







%'} 



('\ 



U , ''-. ' : :-..-..>^i 









']!' 



/// 



'-A \ 



'\\ y ^^- 1> y- ' . vJ 









/ 




Fig. 113. — Horizontal Section of the Vagina and Urethra of an Infant. 
a, a. Skene's glands, h, b, b, b. Urethral glands; the analog of Littre's glands 

in the male. 

The rugce consist of large venous plexuses surrounded by 
bundles of muscle-fibers, as in cavernous tissue. 

The lymphatics are abundantly supplied to the mucosa. 
Lauenstein has described lymph-follicles similar to those in 
the intestine. 

The existence of mucous follicles or glands in the vagina 
is denied; the mucus is believed to be an exudation from the 
vaginal surface. 



140 GYNECOLOGY. 

The nerves ramify throughout the walls, communicate 
with one another and with the ganglia, and terminate in end- 
bulbs beneath the epithelium. 

198. The uterus, or womb, is a hollow, thick- walled, mus- 
cular organ, of a truncated shape, which occupies the upper 
part of the cavity of the pelvis and projects by a portion of 
its cervix into the vagina. It is situated between the bladder 
in front and the rectum behind. The fundus is usually just 
below the level of the plane of the brim of the pelvis, and about 
two centimeters in front of the sacrum. The position of the 
uterus is dependent upon the condition of the surrounding 
organs. When the bladder is empty and the rectum undis- 
tended, the uterus is slightly anteflexed, and occupies a posi- 
tion at a right angle to the axis of the vagina. The fundus 
is directed forward and upward, and the cervix downward 
and backward, toward the rectum. A distended bladder 
raises the fundus and decreases the uterovaginal angle. A 
similar change of position is induced by rectal accumulations 
which push the cervix forward. It necessarily is difficult 
then to determine between a physiologic and a pathologic 
position. We may call any position abnormal in which the 
organ becomes fixed and its range of mobility lessened. The 
uterus presents, from above, a pear-shaped appearance, slightly 
flattened from before backward, and the posterior surface is 
the more convex. 

The length of the virgin uterus is from 5 to 7.5 cm.; its 
breadth at the orifices of the Fallopian tubes, 5 cm. ; and its 
walls are about i cm. thick. The weight of the nonimpreg- 
nated uterus is from about 300 grains to i| ounces. The organ 
is divided into two portions — the body and the cervix. The 
body, pyriform in shape, about 4 cm. long, is surmounted, 
above a line drawn through the orifices of the Fallopian tubes, 
by a rounded portion — the fundus. The cervix, cylindric 
in form, is about 3 cm. long and terminates below in the vaginal 
portion. Schroder divides the cervix into three parts: the 
upper and lower, called the supravaginal and infravaginal por- 
tions, which are separated by an intermediate portion — a 
division which is of significance in the study of uterine dis- 
placements. 

The attachment of the vagina to the uterus is much higher 
behind. When the patient occupies the dorsal position, with 
the limbs well drawn up, the vagino-uterine junction is upon 
a plane vertical to the horizon. The infravaginal portion of 
the cervix is especially interesting to the gynecologist, as it 
is the only part of the uterus which is visible upon inspection, 
and fully accessible to palpation. It varies extremely in size 



ANATOMY. 



141 



and shape, according to the age and sexual relations of the 
individual. In the virgin it presents a conoid projection, 
nearly one centimeter long, with an opening in its apex, known 
as the external os, or os tinc«. The os is a transverse slit, 
about two or three millimeters long, and it divides the cervix 
into an anterior and a posterior lip. The anterior lip is the 
longer. 

With the advent of sexual activity the cervix changes. 




Fig. 114. — Median Section of Uterus from Side to Side through the Fallopian 
Tubes. Mode of Junction of Vagina and Uterus. — (Savage.) 

a. Uterine cavity, b. Cervical canal, showing folding of its]mucous membrane, 
d. Internal uterine (mucous) coat. c. Os externum uteri, e. Uterine 
aperture to Fallopian tube. f. Fallopian tube near uterus, g. Round 
ligament. V. Vagina. 



In the nulliparous married woman it becomes softer and larger, 
the conoid shape is less marked, and the os stands more widely 
open. In the multipara, even when lacerations have not oc- 
curred, the cervix is large and soft, and the os presents a trans- 
verse slit, more frequently an irregular opening. Inflam- 
matory lesions cause the cervix to become still larger, with 
e version of the mucous membrane, erosion of the surface, en- 
largement of the papilla, and an irregular opening. 



142 GYNECOLOGY. 

With the cessation of menstruation, and especially in women 
who have borne a large number of children, the vaginal cervix 
disappears and the os is flush with the fornix of the vagina. 

The junction of the triangular body and conoid cervix is 
called the isthmus. The anterior surface is flattened; the 
posterior, quite convex. The upper border of the uterus is 
rounded, and forms the fundus. The lateral uterine borders 
are obscured by the folds of the peritoneum, known as the broad 
ligaments. The upper part of each ligament is occupied by 
the Fallopian tube; below this, the round ligament; and still 
lower, the ovarian ligament. 

The arteries, veins, and tymphatics of the pelvis pass through 
the broad ligament. 

The uterine canal in the virgin (Fig. 114) is about five centi- 
meters long; slightly longer in the multipara. The cavity 
of the cervix is cylindric, wider in the center and narrower 
at each end,— with the external os below and the internal os 
above. 

The cavity of the body is triangular from side to side, but 
the anterior and posterior surfaces lie in contact. At the apex 
of each angle of the triangle is found an opening, on each side 
the orifices of the Fallopian tubes, and below the internal os. 

The uterine wall has a thickness of a little more than one 
centimeter. The uterus has three layers — an external (serous) , 
a median (muscular), and an internal (mucous membrane). 
The serous or peritoneal covering is not complete, and, there- 
fore, will be considered with the peritoneum. 

The muscle-fibers are best studied in the pregnant uterus, 
and may be divided into three layers. The external is most 
distinct, and consists of a fine, thin layer over the anterior 
and posterior surfaces, from which prolongations are sent off 
into the broad ligament. The posterior fibers form the ovarian 
ligament, and the anterior the round ligament. Some of the 
fibers also furnish the longitudinal muscular structure of the 
Fallopian tube. These fibers are wanting upon the sides of 
the uterus. The middle layer is by far the thickest, and con- 
sists of interlacing fibers, transverse and longitudinal, which 
are continuous with those of the vagina. This layer com- 
prises the principal part of the wall, and contains the blood- 
vessels. The latter are embedded in a network of fibers, and 
may be recognized with the naked eye upon cross-section. 
Their intimate relation to the muscle and tissue is recognized 
by their remaining open when divided transversely. 

The inner layer consists of circular fibers, which are most 
marked at the internal and external os, where they form a 
sort of sphincter, and at the cornu of the uterus, from which 
they are extended into the Fallopian tubes. 



ANATOMY. 



143 



The connective tissue of the uterus is thickly interspersed 
between the muscle-fibers, and especially along the course of 
the vessels. The mucous membrane of the uterine cavity 
rests directly upon the muscle layer without any intervening 
submucosa, and its glandular structure projects between the 
muscle-fibers. In the cervical cavity, where the mucosa is 
thrown into folds, a distinct areolar layer intervenes between 
it and the muscular wall. The uterine mucosa is one milli- 
meter in thickness at the fundus, but becomes thicker near 
the center of the cavity. It 
is smooth and velvety, of a 
grayish-red color, and pre- 
sents no folds, unless in the 




Fig. T15. — Virgin Uterus, Median 
Section. — {Byfoni, after Sappey.) 

I. Anterior surface, 2. Vesico-uter- 
ine pouch. 3, 4, 5, 6. Posterior 
surface. 7. Cavity of corpus. 
8. Cavity of cervix. 9. Os in- 
ternum. 10, II. Vaginal por- 
tion of cervix. 12. Vas:ina. 




Fig. 116. — Mticous Membrane of 
Uterine Body Showing FolH- 
cles. — (Mann.) 

d, d, d. Simple or double culdesac 
of these follicles, a, a, a. Thin 
cup-shaped orifice upon the mu- 
cous membrane. 



immediate vicinity of the tubal opening, and there but a slight 
folding. Under a glass can be seen numerous small depressions 
or openings — the orifices of the glands. The free surface of the 
mucosa is covered with a single layer of columnar epithelial cells, 
which are supplied with cilia. The mucosa is filled with glands 
of the tubular variety, which penetrate its entire thickness, 
and frequently their external extremities are embedded in the 
muscular layer. (See Fig. ii6.) The direction of these tubules 
is more or less oblique. They often exist as sinuous or spiral 



144 



GYNECOLOGY. 



single tubes, but more frequently divide into two or more 
branches near their lower ends. Upon longitudinal section 
they exhibit a basement membrane lined by a single layer 
of prismatic ciliated cells with single large nuclei situated near 
their bases. (See Fig. 117.) These glands largely increase 
with the approach of puberty, and become elongated during 







'\%3,i. 









,m» 



s -^ ^ 



Pig. 117. — Section of Normal Endometrium. Note two glands to right some- 
what enlarged. 
a, a. Glands penetrating muscular substance. 

menstruation, and especially in pregnancy. The mucosa is 
supplied with large plexuses of capillaries and lymphatics. 
The latter, in the form of lymph-spaces, are directly connected 
with the lymph-sinuses and vessels of the deeper layer. The 
termination of the nerve-filaments in the mucosa has not been 
determined, but the action of the glands indicates their reception 



ANATOMY. 



145 



of nerve-filaments, as in similar structures of other parts of 
the body. 

The cervical mucosa, thicker than that of the body, is thrown 
into several folds, known as the arbor vit^, or pliccC palmatae, 
and is separated by a submucosa from the muscular wall. This 
arrangement of the mucosa ends sharply at the internal os, 
and is best observed in the virgin cervix. The mucosa differs 
from the lymphoid structure of the body in having a firm, 
fibrous basement membrane, surmounted by cylindric epithelial 
cells. These cells, according to De Sinety, are ciliated only 
upon the summit of the ridges, while the epithelium covering 
the intervening surfaces is nonciliated. The glands are of the 
racemose variety, consisting of branching ducts. They are 
lined with nonciliated cuboid 
epithelium, resting upon a 
structureless basement mem- 
brane. They open upon the 
free surface, upon and between 
the folds, and secrete a clear, 
viscid, alkaline mucus. The 
ovula Nabothi are those glands 
which have formed small cysts 
after occlusion of their ducts. 

The structure of the cervical 
wall differs from that of the 
body in the increase of fibrous 
tissue, which is intimately inter- 
woven with the muscle-fiber, 
and in the lessened supply of 
blood-vessels. 

The external os presents a 
sharp line of demarcation be- 
tween the one-layered cylinder 
epithelium of the cavity and 
the multiple-layered pavement epithelium of the vaginal portion. 

199. The Fallopian tubes, or oviducts, are two tortuous canals 
which arise from each side of the fundus uteri. They vary 
in size and length, occupy the upper margin of the broad liga- 
ment, and extend outward almost to the pelvic brim. The 
length of the tube is from 7.5 cm. to 12.5 cm., the right tube 
usually being the longer. 

They are first directed outward, then backward, and finally 
inward, giving the appearance of a shepherd's crook. The 
tube presents for our study: first, in the uterine cavity a narrow 
funnel-like opening, the ostium uterini tubas; 2, the section 
of the canal found in the uterus, pars uterini; 3, the narrow 

10 




Fi« 



Virgin Os and Cervix. — 
{Sappey.) 



146 GYNECOLOGY. 

portion proximal to the uterus, the isthmus tubse; 4, a wider, 
longer, more tortuous portion, the ampulla tubae, which ter- 
minates in, 5, a distinct trumpet-shaped end, the infundibular 
tubae, provided with numerous fimbrice, and 6, a distinct open- 
ing from the ampulla, the ostium abdominale tubse. The line 
of differentiation between the pars uterini, isthmus, and am- 
pulla is not sharply defined. The isthmus is the narrowest 
portion and is about two centimeters long. The diameter 
of the isthmus is about two millimeters, and its lumen will 
scarcely admit a bristle. The ampulla is the more widened 
part; it extends outward and backward, has an external di- 
ameter of from six to eight millimeters, and its lumen a 
diameter of two or three millimeters. 

The fimbriated extremity — also called the pavilion, or in- 
fundibulum, from its funnel shape, and the morsus diaboli 
(devil's mouth) — is a trumpet-shaped opening, surrounded 
by primary and secondary fimbrice, which resemble the tentacles 
of the sea anemone. The primary fimbriae are the larger pro- 
cesses, four or five in number, from which arise the eight or 
ten secondary processes. 

The longest fimbria (fimbria ovarica) anchors the tube to 
the ovary and has a furrowed groove, which facilitates the 
passage of the ovum to the tubal orifice. The broad ligament 
is continued to the, lateral wall of the pelvis by a small fibrous 
band, known as the infundibulopelvic ligament. 

The tube, upon repeated section, will be found to have 
varying dimensions, and frequently its course is tortuous, 
almost convoluted. It has two openings — the uterine and 
the abdominal. The latter is more distensible than the remain- 
ing portion of the tube, is somewhat trumpet-shaped, and 
affords a communication with the peritoneal cavity. 

The tube has four coats: the external, a serous, which is 
separated from the muscular by a subserous coat, the tunica 
adventitia; the middle, a muscular; and the internal — the 
mucous membrane. 

The external serous covering is incomplete, that portion 
of the tube toward the broad ligament being incomplete for 
the inner two-thirds of the tube. The remaining third is sur- 
rounded by the peritoneum, which covers the external surface 
of the fimbriae, while the internal is lined by the mucosa. The 
tunica adventitia envelops the muscular layer, allowing the 
peritoneal to slip over its abdominal end. The muscular coat 
consists of longitudinal and circular fibers. The former is 
continuous with the outer; the latter, however, is predominant 
and the continuation of the inner muscular layer of the uterus. 
The muscular structure is more largely developed at the prox- 



ANATOMY. 



147 



imal than at the distal end of the tube, and the circular fibers 
are particularly well marked at the isthmus, where they form 
what is called the sphincter tub^. The tubal mucosa is quite 
thick, thrown into longitudinal folds, very vascular, and of a 
bright red color. In the isthmus the mucosa presents simple 
folds, which become more complex in the ampulla. Hennig 
has counted from three to five primary folds, which have be- 
tween eight and ten smaller plicae between each pair of the 
former. The secondary folds are less marked near the abdo- 
minal extremity, where the longitudinal folding is apparent 
to the naked eye. 

The mucosa has a single layer of ciliated columnar epithe- 












Fig. 119. — Section of Fallopian tube through the isthmus. 
a, a, shows the firm and compact structure of the longitudinal folds in this 

portion of the tube. 



Hum Upon two or three layers of supporting cells, which are 
round or pyriform. The cells abruptly terminate at the ends 
of the fimbria, where the margin between the columnar and 
pavement epithelium is distinctly marked. The tubal mucosa, 
like the uterine, has no distinct submucous layer, but unlike 
the latter it is without glands, and is covered with a thin layer 
of grayish mucus of a distinctly alkaline reaction. 

200. Ovaries. — The ovaries, the germ -bearing organs of 
the woman, and the analogs of the male testicle, are a pair of 
small bodies, situated one upon the posterior surface of each 
broad ligament, below the tube and at each side of the uterus. 



148 GYNECOLOGY. 

The ovaries occupy a position at the level of the brim of 
the pelvis, or partly below and partly above its plane. 

The axes of the ovaries lie obliquely to the pelvis, with a 
slight inclination forward. In the erect position they rest 
upon the posterior surface of the broad ligament. 

The Fallopian tube is situated in the broad ligament above 
the ovary and partly encircles it, while the round ligament is 
in front and occupies the anterior fold of the broad ligament. 
In front of the ovary, between it and the tube, is the parovarian 
structure, or the organ of Rosenmuller. The inner or uterine 
extremity of the ovary is connected with the uterus by some 
muscle-fibers, about three centimeters long, known as the 




Fig. 120. — Section of the Fallopian tube through the ampulla near the isthmus, 
showing extensive folding of the mucous membrane. 

ovarian ligament; the outer or tubal extremity is connected, 
above, with the end of the tube through the fimbriae ovarica, 
and below, with the infundibulopelvic ligament. 

The ovary presents a flattened, ovoid appearance, with its 
broad end directed externally and the pointed end toward 
the uterus. The anterior, straight or flattened surface of the 
ovary is fixed by a short serous duplication, the mesovarium, 
to the posterior surface of the broad ligament. The posterior 
convex margin is free. Its size varies with the age of the in- 
dividual, the functional activity of the organ, and the occurrence 
of menstruation or pregnancy. The ovary attains its greatest 



ANATOMY. 149 

size about six weeks after parturition (Hennig), and never 
reaches its former size in the subsequent involution. 

Following the menopause, it shrinks to one -half or one- 
third of its dimensions during active sexual life. Luschka gives 
its dimensions as: length, 4 cm.; width, 2.2 cm.; thickness, 
1.3 cm. It weighs from 60 to 135 grains. 

The color of the ovary is a pinkish-gray, becoming some- 
what darkened as menstruation approaches. Immediately 
after ovulation a dark swelling follows, due to the accumulation 
of blood. As absorption progresses the color changes, and 
the mass becomes yellow, and later presents only a whitish 
cicatrice. Before puberty the ovary is smooth, but subse- 
quently it becomes irregular, from the cicatrices following 
repeated rupture of cysts, or nodular, from the presence of 
matured follicles that have failed to rupture. Following the 
menopause, the ovary becomes a pearly-white, irregular, almost 
cartilaginous mass, about one-half or one-third its former size. 

The ovary is situated upon the posterior surface of the 
broad ligament, with its pointed end connected with the uterus 
by the ovarian ligament. The ovary, by its pointed end, is 
directed toward the ligament, and its stroma extends inward 
upon the latter, while the external ovarian end is blunt and 
large. The posterior surface of the ovary projects through 
the peritoneum, and is uncovered by it. The union of the 
columnar epithelium of the ovarian surface with the pavement 
epithelium is readily recognized as a white line, and is called 
the white line of Farre. 

Sections of the healthy ovary show two kinds of tissue, a 
central or medullary, and a cortical or peripheral portion. 
The latter covers the entire surface of the ovary bounded by 
the line of Farre, but projects to its greatest depth (two to 
three millimeters) at the central portion of the convex surface. 
The central structure has a pinkish-gray or rosy color, is of 
soft consistence, and has a moist glistening appearance. It 
is of a white or grayish-white color, more or less firm in con- 
sistency, and contains numerous small vesicles. The smaller 
vesicles are situated near the surface, while larger cysts are 
situated deeper. Some of these reach the size of a pea, and 
may project more or less beyond the free surface. The sac- 
wall is frequently so thin that the vesicles rupture under the 
slightest pressure. This layer also contains numerous depres- 
sions, or scars, the result of repeated ovulation. 

The cortical layer of the ovary, or that part which projects 
through the peritoneum, is covered by a single layer of short, 
columnar epithelium, called by A¥aldeyer the germinal epithe- 
lium. This terminates abruptly at the white line, where the 



150 



GYNECOLOGY. 



pavement epithelium of the peritoneum begins. Before puberty 
young ova are represented by large spheroid cells, with marked 
nuclei, which form in the columnar cells. Ingrowths of the 
germ epithelium into the underlying stroma are occasionally 
seen, which form the ovarial tubes of Pflliger. 

Immediately beneath the epithelial layer, and quite insepa- 
rable from the underlying stroma, is the tunica albuginea — a 
thin, dense layer of fibrous tissue, which contains a few smooth 




Fig. 12 1. — Section of Ovary, Showing Graafian Follicles. — (Wyder.) 



muscle-fibers. It is not completely developed until the third 
year, and undergoes changes with age and inflammation until 
it becomes thickened and of almost cartilaginous hardness, 
which renders its rupture exceedingly difficult. Such alterations 
from inflammatory changes are a cause of the formation of 
retention cysts, and of the development of that condition known 
as cystic disease of the ovaries. The structure of the ovary, 
as already noted, is divided into a cortical and a medullary 
portion, although they differ but little in structure except that 



ANATOMY. 151 

the latter is softer and more vascular. In the cortical layer 
lie the Graafian follicles, embedded in connective tissue, inter- 
spersed with some muscle-fibers. A large number of these 
follicles, variously estimated at from 36,000 to 400,000, are 
found in each ovary. Whether so large a number exists is 
difficult to determine, but it remains evident that nature has 
amply provided for the reproductive function. 

The ovarian stroma is the framework or bed in which the 
follicles rest and are nourished. Each Graafian follicle has a 
wall, which consists of a tunica fibrosa of thin fibrous tissue, 
within which is a more delicate membrane, called the tunica 
propria; the latter contains many granular cells and a fine 
network of capillary vessels. This tunica propria is lined with 
several layers of epithelial cells, called the membrana granulosa. 
These ■ cells are separated from the tunica propria by a struc- 
tureless membrane. These epithelial cells form a thickened 
mass upon one side, which projects into the cavity — the discus 
proligerus. The cavity of the follicle is filled with a clear, 
serous fluid, called the liquor folliculi. It is formed by lique- 
faction of the cells of the membrana granulosa. 

The Graafian follicle, when mature, is one millimeter in 
diameter. Embedded in the discus proligerus is found the 
ovum, which has been called the typical cell; it measures from 
0.2 to 0.3 mm. It is a yellow, spheroid body, enveloped by 
a thin, delicate membrane, — the vitelline membrane, or zona 
pellucida, doubtless formed from the innermost cells of the 
discus proligerus. Within this membrane is contained the 
vitellus, a network of granular, fibrillated protoplasm containing 
numerous fat-globules. In the outer portion of this network 
is a light spot, which consists of fine, fibrillated protoplasm, 
which contains in its meshes a granular material inclosed in a 
distinct membrane. This structure is known as the nucleus, 
or germinal vesicle. Within this is contained a small, highly 
refracting, granular body, known as the nucleolus, or germinal 
spot. 

The Graafian follicle is surrounded by a vascular network; 
as it matures, the liquor folliculi increases, the cyst becomes 
tense, approaches the surface, and the tunica albuginea be- 
comes thinned and finally ruptures, permitting the ovum to 
escape. The cavity of the follicle fills with blood, which coag- 
ulates and forms a clot. Later, this clot presents an external 
yellowish color, while its center is of a reddish-gray hue. The 
clot gradually becomes organized, contracts (by which it is 
thrown into folds), and is gradually absorbed. The clot thus 
formed is known as the corpus luteum. The ovary of a normally 
menstruating woman will be found to contain a number of 



152 



GYNECOLOGY. 



corpora lutea in various stages of retrogression. The structure 
generally disappears by the end of the twelfth week, excepting 
a small cicatrice, which remains. 

When pregnancy occurs, the corpora lutea do not continue 
to form, but the one corresponding to the last menstruation 

becomes much larger and 
remains longer. It con- 
tinues to increase, and 
after the first month 
forms a large yellow 
clot, which gradually be- 
comes decolorized and 
more highly organized, 
resulting in a white, fi- 
brinous clot surrounded 
by a yellow ring. The 
corpus luteum of preg- 
nancy is known as the 
corpora lutea vera, while 
those which occur with 
ordinary ovulation are 
called corpora lutea 
spuria. 

Later in the pregnan- 
cy, the time of which is 
not exactly known, it 
becomes contracted, and 
at its termination forms 
a mass about 0.5 cm. in 
diameter. 

When the corpus lu- 
teum has lost its color 
and most of its blood- 
vessels, and is mainly 
composed of a mass of 
fibrous tissue, it is called 
a corpus albicans. Fre- 
quently, from the reten- 
tion of pigment, it is dark 
in color, and is known as 
a corpus nigricans. Clark has shown that the corpus luteum 
finally disappears by the process of hyahne degeneration. Ex- 
travasations of blood, or apoplexy of the ovary, we shall see 
later, are not infrequent, and occasionally may result in the 
complete destruction of the organ and the formation of a blood- 
sac — an ovarian hematoma. 




Fig. 122. — Large Corpus Luteum in Associa- 
tion with an Ovarian Dermoid. Re- 
moved from an Unmarried Woman "Who 
Had Never Been Pregnant. — (Sutton.) 

I. Twisted pedicle. 2. Corpora luteum, 3. 
Old clot. 4. Integumentary surface of 
dermoid. 



ANATOMY. 153 

201. The Parovarium. — Between the outer end of the tube 
and the ovary is situated a triangular group of small tubules, 
known as the parovarium, or the organ of Rosenmiiller — a 
remnant of the Wolffian body. 

The structure corresponds to the epididymis in the male. 
The apex of the triangle is directed toward the ovary. This 
organ is of especial importance to the gynecologist, as it can 
be the seat of a number of growths. It consists of from six 
to thirty spiral tubules, Avhich at their base open into a single 
transverse tube. This transverse tubule corresponds to the 
canal of Gartner in the lower animal. Cysts are frequently 
found associated with the tubules; the most common is the 
hydatid of Morgagni, or appendix vesiculosa, the pedicle of 
which arises in a point of the mesosalpinx, near the fimbria 
ovarica. The occurrence of this cyst is the rule rather than 
the exception, and it consists of a tough connective-tissue 
wall with a well-developed vascular system, and is lined with 
pavement epitheliura. It has a pedicle one-third centimeter 
long and contains clear fluid. The parovarium is entirely 
a rudimentary structure, and has no function. 

202. Urinary Organs and Rectum. — Our knowledge of the 
relations of the pelvic organs will be incomplete without a 
study of the analogy of the urethra, bladder, and ureters, as 
well as of the rectum and anus, 

203. The urethra is a canal, from 2.5 cm. to 4 cm. long, 
which forms the outlet to the bladder. It lies embedded in 
the anterior vaginal Avail, from which it can readily be separated. 
It is slightly curved upward, with its concavity forward. Upon 
cross-section the urethra presents a transverse slit near its 
vesical end and a stellate folding toward the external meatus. 
The diameter of the urethra is 0.6 cm., and it is quite distensible. 
When not distended, the urethral mucous membrane is more 
or less corrugated throughout its length, owing to the sphincter- 
like action of the surrounding muscle-fibers. The urethra 
is attached to the pubic arch by the pubovesical ligament, 
and penetrates the triangular ligament, between the layers 
of which it is surrounded by the fibers of the compressor ure- 
thra, or muscle of Guthrie. 

It is also, together with the vagina, influenced at its lower 
end by the bulbocavernosus muscle. Its external opening 
is known as the external meatus, and close inspection of its 
orifice will reveal a number of small openings about it — the 
orifices of the glandule vestibulares minores. Within the 
meatus are two small openings — the orifices of the tubules, 
described by Skene. They correspond to the lacuna magna 
in the fossa navicularis of the penis. 



154 GYNECOLOGY. 

' They are described by Skene as tubules which extend for 
a distance of nearly one centimeter parallel with the urethra. 
As a result of inflammation they can be so dilated that they 
will admit a No. i probe, and even the point of a catheter. 

The urethra is nearly parallel with the bladder, but when 
the woman is erect it is nearly vertical. 

The urethral mucous membrane, like that of the vestibule, 
is of the pavement variety. The glands are lined at their 
mouths with pavement epithelium, which soon changes into 
the columnar variety. 

204. The bladder is situated in the anterior part of the 
pelvis, between the symphysis pubis in front, and the vagina 
and uterus behind. Its shape is constantly changing with 
the accumulation and evacuation of the urine. When empty, 
the urethra forms the stem of a Y, the anterior limb of which 
is the longer. Between the urethra, the anterior surface of 
the bladder, and the symphysis is a triangular space filled with 
the retropubic fat. The bladder, when moderately distended, 
becomes rounded; and when full, oval. The female bladder 
holds less than that of the male, and differs from it also in having 
the transverse diameter longer than the vertical. The bladder 
is divided into three portions: the body; the base, or fundus; 
and the neck. Skene defines the former as that portion which 
lies above a plane formed by the ureteric openings and the center 
of the symphysis pubis. The portion below is the fundus, or 
base, which includes the trigone, or space between the orifices 
of the ureters and internal meatus, and the bas fond, the space 
immediately behind the ureters. The thickened surface about 
the urethral orifice is the neck, which is the most dependent 
portion when the body is erect. 

The bladder-wall consists mainly of muscular structure. 
The wall, dependent upon the amount of distention, varies 
from 0.5 to I cm. The muscular structure consists of lon- 
gitudinal and circular fibers, the former mostly confined to 
the anterior and posterior surfaces. They may be traced 
from the vesical neck and pubes in front, where they are called 
the musculi pubovesicales, to the summit, where some of the 
fibers accompany the urachus. 

The circular fibers are more marked near the vesical orifice, 
where they form the sphincter vesicae. 

The muscular layer is partly covered externally by the 
peritoneum, which will be discussed later, and internally by 
the mucous membrane, with which it is loosely connected by 
a layer of fibrous and elastic tissue. Because of this loose 
connection, the mucous membrane is thrown into folds when 
the bladder is empty, except at the trigone, where it is more 



ANATOMY 



155 



intimately connected with the submucous layer and is much 
thinner. 

The mucous membrane in life presents a rosy pink appear- 




Fig. 123. — Vesicovaginal Septum and Base of Female Bladder. Anatomic 
Relations of Ureters at Their Entrance into the Bladder. Contents of 
Alar Ligament. — (Savage.) 

I, I. Ureters. 2. Uterine artery. 3. One of the uterine veins. 4. Dotted 
line indicating the vaginal end of the uterine cervix. 5. Internal meatus 
urethrse. 6. Ligamentous process of fascia of pubococcygeus muscle and 
vesicopubic muscles. 7. PubococcA'geus muscle. U. L'terine body. O. 
Ovary, utero-ovarian muscular ligament, and grooved Fallopio-ovarian 
fimbriae. T. Fallopian tube and fimbria inverted. M. Parovarium. P. 
Pubic arch. V. Bodv of bladder. 



ance, and is continuous with that lining the urethra and ureters. 
Its epithelium consists of three or more layers of epithelium 
resting upon a basement membrane. The superficial cells are 



156 GYNECOLOGY. 

squamous, but are smaller than the vaginal. The inferior 
layer is composed of columnar epithelium with long processes, 
while the middle one is made up of pyriform cells. The mem- 
brane is supplied with a rich plexus of fine capillaries and nerve- 
fibers; the latter are not marked in the trigone. 

The bladder is but poorly supplied with lymphatics, and 
they communicate with the glands near the internal iliac artery. 

205. The ureters are the urinary ducts through which the 
urine is carried to the bladder. Their course, previous to 
crossing the iliac arteries, is nearly parallel. The left ureter 
lies behind the sigmoid flexure of the colon. In their subse- 
quent course the ureters extend downward, backward, and 
outward, along the lateral walls of the pelvis. At the spine 
of the ischium they bend downward, forward, and inward to 
the bladder, passing behind the uterine arteries, and about 
I to 1.5 cm. on each side of the cervix. The distance between 
the ureters where they enter the bladder is 5 cm. They pass 
obliquely through the vesical wall and enter the bladder 2 
cm. below and external to the cervix, where their orifices are 
still 4 cm. apart, but united by a prolongation of the longitudinal 
fibers of the ureter, known as the interureteric ligament. This 
ligament forms a transverse ridge between the two orifices, 
and serves as the base of the vesical triangle. 

206. The Rectum. — The rectum is the lower extremity of 
the large intestine, and begins with the termination of the 
sigmoid flexure, at the level of the third sacral vertebra, to end 
with the anus. The rectum in its course from the third sacral 
vertebra is directed downward and forward behind the cervix 
uteri and vagina, parallel with the latter, until it turns directly 
backward at the anus. The relation of the rectum to the pelvic 
structures naturally divides it into two portions, the pelvic 
and the perineal portion. The pelvic portion begins opposite 
the third sacral vertebra and ends at the insertion of the levator 
ani into its wall. The perineal portion lies between the muscle 
and the anus. The space formed by the deviation of the rectum 
from the line of the vagina is occupied by the perineal body. 
The portion of the rectum involved in this deviation, which 
is about 2.5 cm. long, is known as the anus. 

The entire length of the female rectum is twenty centi- 
meters. The canal is less curved than in the male and its caliber 
is greater. The longitudinal muscular bands so characteristic 
of the colon are absent. 

The rectum, artificially distended, shows a very large sac, 
immediately above the anus, which decreases as the sigmoid 
flexure of the colon is approached. This very dilatable portion 
is called the ampulla, and when empty the anterior surface 



ANATOMY. 157 

lies in contact with the posterior, so that upon transverse section 
it presents a transverse sht. 

The anal orifice is quite dilatable. The anus forms an 
aperture which closes with its lateral surfaces in contact. The 
orifice is further obstructed by eight or ten longitudinal folds 
of the mucous membrane. These folds are called the "columns 
of Morgagni," and the depressions between them, the "sinuses 
of ]\Iorgagni." These corrugations are produced by the con- 
traction of the sphincter, and disappear when the anus is dis- 
tended. Above the anus are three ring-like zones which are 
superimposed over each other. The first is the zone of the 
rectal columns and the intervening sinuses. The mucous 
membrane upon the surfaces of the columns is covered with 
pavement epithelium, while in the depressions cylindrical 
epithelium similar to that of the bowel above is found. Lie- 
berkuhn's crypts are seen only in the upper portion of this 
zone. Its boundary is often recognized as a distinct line, the 
linea ani rectalis (Hermann). The middle zone has a smooth, 
bright mucous membrane covered with pavement epithelium 
and small papillae. The lower zone is the cutaneous zone. 
This has the horny epithelium well supplied with pigment 
and also the connective-tissue sub-layer characteristic of the 
skin. We find here papilla, hair, and sebaceous glands, ad- 
joining the large convoluted glands of the intestine. The 
submucous layer consists of a structure of quite dense con- 
nective tissue, in which are situated the blood-vessels, nerves, 
and lymphatics. Its laxity permits the mucous membrane to 
glide over it. The mucous membrane of the rectum above the 
anal canal has three or four large permanent transverse or ob- 
lique semilunar folds which often project quite a distance into 
the lumen of the bowel. These folds, according to Gant, are 
crescent-shaped, capable of some vertical motion, and extend 
about one-half to two-thirds the circumference of the rectum 
and project into its lumen from three-fourths of an inch to an 
inch and a half. They are situated obliquely to the long axes 
of the bowel. They are slightly cup-shaped with the con- 
cavities looking upward. With the bowel distended the free 
margins of these valves are prominent and readily seen through 
the proctoscope. They are called Houston's valves. The 
number of them is variable; usually there are three. In ex- 
ceptional cases there may be five, six, or even seven. Their 
location is fairly constant. The upper valve is situated at 
the junction of the sigmoid and the rectum on the left rectal 
wall. The middle, which is the most prominent, occupies 
the right anterior wall opposite the base of the bladder and is 
three inches or more above the anus. The lower valve is situated 



158 



GYNECOLOGY. 



on the left side and a short distance below the middle valve. 
With the patient in the knee-chest posture and the rectum 
well inflated, one can often see, by the aid of the proctoscope, 
all these valves at the same time. They generally form a sort 
of spiral stairway which gives a rotatory motion to the fecal 
mass as it progresses toward the anus. 



URETER (behind PERITONEUM 
LOOP OF SMALL INTESTINE 



VERMIFORM APPENDIX 
CECUM (displaced UPWARd) 





DEEP EPIGASTRIC A 
OBLITERATED HYPOGASTRIC A 
EXTERNAL ILIAC A (BEHIND PERITONEUM 



FUNDUS OF UTERUS 

FIMBRIATED EXTREMITY OF FALLOPIAN TUBE 

SIGMOID FLEXURE (DISPLACED UPWARD) 



LOOP OF SMALL INTESTINE 



APPENDICULO-OVARIAN LIGAMENT 





ROUND LIGAMENT 



BLADDER (dISTENDED) 



FALLOPIAN TUBES 



Fi 



g. 124. 



URACHUS 

-Superior View of the Pelvic Cavity.— {De aver.) 



The rectal wall is composed of three coats — the peritoneal, 
the muscular, and the mucous membrane. 

The arrangement of the serous coat will be considered with 
the peritoneum, but it should be remembered that a portion 
only of the rectum is enveloped by peritoneum. The mus- 
cular layer consists of longitudinal and circular fibers, but 



ANATOMY. 159 

the former are more generally distributed, and not collected 
into bands, as in the colon. The circular fibers are deeply 
situated, and are more marked just above the anus, where they 
form a distinct ring, nearly half an inch in width, which is re- 
cognized as the internal sphincter. The submucous layer 
consists of a layer of quite dense connective tissue in which 
are situated the blood-vessels, nerves, and lymphatics. Its 
laxity permits the mucous membrane to glide over it. The 
mucous membrane is continuous with that of the intestine, 
although much thicker and more movable than that of the 
colon, and its great vascularity causes it to have a bright pink, 
or even red, color. 

The mucous membrane is lined with columnar epithelium, 
and contains a large number of Lieberkiihn's follicles, but no 
villi. The mucous membrane at the anus abruptly changes 
from the columnar to the pavement epithelium of the skin, 
which forms the so-called white line. 

207. Pelvic Peritoneum. — That portion of the serous lining 
of the abdominal cavity which is situated within the pelvis, 
and envelops the pelvic organs, is known as the pelvic perito- 
neum. Upon examination of a mesial section it will be seen 
to leave the anterior abdominal wall about three centimeters 
above the symphysis and be reflected upon the fundus of the 
bladder. It covers the posterior surface of the bladder to 
the level of the internal os, and as much of the lateral surface 
as lies behind the obliterated hypogastric arteries. (Fig. 125.) 
From the bladder it crosses over to the uterus, the anterior sur- 
face, fundus, and entire posterior surface of which it invests. (Fig. 
126.) Laterally from the anterior surface it extends outward 
upon a plane perpendicular to the pelvic brim, and is attached 
to the lateral wall of the cavity, thus forming the anterior fold 
of the broad ligament. The peritoneal investment posteriorly 
extends over the uterus and upon the upper part of the vagina, 
nearly three centimeters below the uterovaginal junction. 
The lateral prolongation of this portion forms the posterior 
border of the broad ligament. The broad ligament contains 
the round ligament in its anterior fold; the Fallopian tube 
in its superior border, between the anterior and posterior folds; 
and its continuation from the termination of the tube is known 
as the infundibulopelvic ligament, the integrity of which is 
of importance in maintaining the ovary, and even the uterus, 
in position. Resting upon and projecting from the posterior 
fold, when the patient is erect, is the ovary, which is attached 
to the uterus by the ovarian ligament. The anterior and 
posterior leaflets of the broad ligament are separated, in addition 
to the structures named, by considerable loose, Avascular, con- 



160 



GYNECOLOGY. 



nective tissue, and afford entrance for the ovarian and uterine 
arteries and nerves, and egress for the veins and lymphatics, 
while its base is penetrated by the ureter on its way to reach 
the bladder. From the vagina the peritoneum is reflected 
backward, to be attached to the anterior surface of the rectum 




Fig. 125. 



-Curved Dotted Line Shows Covering of the Anterior Uterine Wall 
by Peritoneum. — (Winter.) 



and to the tissues in front of the sacrum. Above the promon- 
tory of the sacrum it is continuous with the posterior abdo- 
minal peritoneum. 

The reflection of the peritoneum over the uterus and its 
extension as the broad ligaments upon each side divide the 




Fig. 



126. — Posterior Surface of Uterus Showing Extent of Peritoneum; 
Fallopian Tubes, Ovaries, and Ovarian Ligaments. — (Winter.) 



also 



pelvis into two culdesacs — the anterior, or vesico-uterine, 
and the posterior, or uterorectal. The posterior culdesac is 
further divided by a prolongation of muscular structure from 
the sides of the uterus backward to the ileosacral synchondrosis, 
over which the peritoneum is reflected. This forms a deep, 



ANATOMY. 



161 



cup-shaped cavity directly behind the uterus, which is known 
as the pouch of Douglas. This pouch dips deeper on the left 
side, and sometimes extends to the upper border of the perineal 
body. When the bladder is empty and the nonpregnant uterus 
lies forward, the coils of small intestine usually occupy this 
pouch except as its very lowest point, and intra-abdominal 
pressure sometimes causes its dissection downward until a 
distinct hernia occurs behind the uterus. On either side, ex- 
ternal to the uterosacral ligaments, is a fossa, which is known 
as the para -uterine pouch. This has been called by Polk the 
retro-ovarian shelf. On the side wall of the para-uterine pouch 




Fig. 127. — Vertical Transverse Section of the Pelvis, Showing Peritoneal Pouches. 

— (Luschka.) 
I, I. Levator ani muscle. 



the ureter may be seen beneath the peritoneum. This space 
is occupied by the small intestine. During pregnancy the para- 
uterine pouch is lifted up to the pelvic brim, while Douglas' 
pouch remains unaffected. From before backward, we may 
find the following pouches or depressions: first, the pubovesical; 
second, the vesico-abdominal, which is seen only during dis- 
tention of the bladder, and varies in depth according to the 
point at which the serous lining of the abdominal wall is re- 
flected. The vesico-uterine pouch is bounded in front by the 
bladder; posteriorly, by the uterus. This pouch varies less 
11 



162 GYNECOLOGY. 

than the others, on account of the firm attachment of the perito- 
neum to the anterior surface of the uterus. In the empty 
bladder the bottom of this pouch is about three centimeters 
distant from the anterior culdesac of the vagina, and the pouch 
rises somewhat as the bladder falls. The study of the female 
peritoneum renders it evident that it differs from that of the 
male in not being a closed sac, as it communicates with the 
uterine mucous membrane through the orifice of the Fallopian 
tubes, and is again perforated by the ovaries, which project 
through it. The close relation of the peritoneum to the pelvic 
viscera renders any change in this structure perilous to the 
normal situation and relation of these organs. Inflammatory 
changes result in thickening and cicatrization, which produce 
temporary, if not permanent, displacements. The fixation 
of the uterus, compression of the ovaries, and obstruction of 
the orifices of the Fallopian tubes are necessary sequels of 
such alterations. The peritoneum, according to Luschka, 
serves as a sort of diaphragm, dividing the pelvic cavity into 
two portions ; the one above may be called within the peritoneal 
space, and that below, the subperitoneal. In the latter is 
situated the greater part of the pelvic connective tissue. 

208. Pelvic Connective Tissue. — The pelvic connective tissue 
is a loose cellular tissue, which acts as a padding for the support 
and safety of the pelvic organs. This structure is continuous 
with that which exists in other portions of the body. It appears 
in the pelvis in two varieties : first, as a loose tissue, distributed 
in an irregular manner around and between organs, and between 
the layers of the broad ligaments, where it acts as a support to 
the blood-vessels and folds of the peritoneum; second, as firm, 
well-defined laminse or planes entering into the formation of the 
pelvic floor. These have already been described under the name 
of pelvic fascia. The connective tissue is continued behind the 
symphysis as the retropubic fat, and there lies in front of the 
bladder. Between the base of the bladder and the vagina it is 
rather firmly connected. On the posterior surface of the vagina 
there is a very loose layer connecting it with the rectum. A 
large mass is found on each side of the cervix uteri, forming under 
the broad ligaments what is known as the parametrium, which 
is united in front and behind by a much thinner layer. Over the 
body of the uterus the connective tissue is very slight and con- 
tains no fat. The rectum and vagina are embedded in consider- 
able masses of this tissue. From the uterus and the parametrium 
a thin layer extends between the leaflets of the broad ligament, 
and serves as a support for the vessels. The chief mass of this 
tissue is situated around the cervix, and extends downward 
around the vagina to the insertion of the levator ani muscle. 



ANATOMY. 163 

The distribution and relation of the pelvic connective tissue have 
been studied in different ways. The most valuable method is by 
the examination of frozen or spirit -hardened pelves, by which the 
position of the tissue, its amount, and its distribution are recog- 
nized. Injections of air, Avater, and plaster-of-Paris have been 
made beneath the pelvic peritoneum in order to determine the 
lines of cleavage in the pelvic connective tissue and the directions 
in which pus would be likely to burrow. Konig made investiga- 
tions upon the bodies of women who had died shortly after labor 
from nonpuerperal disease. AVhen an injection is made between 
the layers of the broad ligament, high up in front of the ovary, 
it first passes into the tissue at the highest part of the side wall 
of the true pelvis; then into the iliac fossa, lifting up the peri- 
toneum; follows the course of the psoas, and passes but slightly 
into the hollow of the iliac bone; finally, it separates the peri- 
toneum from the anterior abdominal wall some little distance 
above Poupart's ligament, and from the true pelvis below it. 
Second, when the injection is made beneath the base of the 
broad ligament and in front of the isthmus, the deep lateral 
tissue becomes filled first ; then the peritoneum is lifted from the 
anterior part of the cervix uteri. Separation extends to the tissue 
in the bladder, and ultimately along the round ligament and the 
inguinal ring, where it separates the peritoneum along the line 
of Poupart's ligament and enters the iliac fossa. Third, an in- 
jection at the posterior part of the base of the broad ligament 
fills the tissues around Douglas' pouch, and then follows the 
course as first described. 

209. The Vascular Supply. — The pelvic organs and perito- 
neum are supplied through the ovarian, uterine, vaginal, and 
internal pudic arteries. The ovarian arteries, analogs of the 
spermatic in the male, arise from the abdominal aorta just 
below the renal branches and pass downward over the psoas 
muscles, beneath the ureters, enter the broad ligaments, and 
pass to the side of the uterus, near which each divides into two 
branches. The upper supplies the fundus uteri, and the lower 
anastomoses at the side of the uterus with the anastomotic branch 
of the uterine artery. In its course the ovarian artery gives off 
branches to the ampulla of the Fallopian tube and to the isthmus, 
and also numerous branches to the ovary. A small branch 
is given off to the round ligament. The uterine artery springs 
from the anterior division of the internal iliac, passes downward 
and inward toward the cervix uteri, then upward between the 
layers of the broad ligament in a very tortuous course, and 
anastomoses with the lower branch of the ovarian. This portion 
is sometimes called the anastomotic branch, or the puerperal 
branch, as by its tortuous course it permits the vessel to be 



164 



GYNECOLOGY. 



straightened out during the enlargement of the uterus in preg- 
nancy. The primary branches given off by the uterine artery 
are separated from the peritoneum only by a thin layer of muscle- 
fibers. These give off secondary branches, which penetrate the 
muscular wall in a direction at right angles to its mucous layer. 
They anastomose freely and end in capillary loops in the mucous 
membrane. The vaginal branches spring direct from the ante- 
rior trunk of the internal iliac, but sometimes are given off from 
the uterine or the middle hemorrhoidal. A special branch of the 
uterine artery to the cervix joins with its fellow of the opposite 
side to form the circular artery of the cervix, and with the 
vaginal branches forms the azygos artery of the vagina. Ex- 




Fis:. 128. — Distribution of the Uterine and Ovarian Vessels. 



tensive anastomoses take place between the vessels of the oppo- 
site sides. The entrance of the vessels by the broad ligament 
enables us in extirpation of the uterus to control hemorrhage 
by ligation of the latter. The anterior division of the internal 
iliac also affords the blood supply to the bladder and rectum. 
The perineal region is supplied by branches from the internal 
pudic artery — a branch of the anterior trunk of the internal 
iliac. It passes out through the greater sciatic notch and enters 
through the lesser, passing around the spine of the ischium. In 
its course it lies upon the internal obturator muscle, and is 
inclosed with the pudic nerve in a canal formed for it by the 



ANATOMY. 



165 




^22 



Fig. 129. — xVrteries of the Female Pelvic Organs. — (Savage.) 

Vena cava inferior, receives right and left common iliac veins. 2. External 
iliac vein. 3. Abdominal aorta. 4. Inferior mesenteric artery. 5. 
Right common iliac artery. 6. External iliac artery. 7, Epigastric 
artery. 8. Obturator branch of epigastric artery. 9. Internal iliac 
artery, crossed in front by h, the ureter. 10. Uterine artery. 11. Obtu- 
rator artery; its course is along with and below m, the obturator nerve. 
L. Round ligament. 12. Inferior vesical artery. 13. Vaginal branch 
from it. 14. Uterocervical artery. 15. Artery of the Fallopian tube. 
18. Vaginal artery. 17, 17, 17. Spermatic arteries. 19. Pudic artery. 
20. Superior vesical artery. 21. Inferior hemorrhoidal artery, joined at 
22, another inferior vesical branch. 23. Posterior division of internal 
iliac artery, terminates in (24) iliolumbar lateral sacral, and (25) gluteal. 
26. Sciatic arteries. B. Bladder. O. Urachus. V. Vagina undistended, 
resting on (R) the rectum. O. Ovary. T. Fallopian tube. 15. Fallo- 
pian branch. U. Uterus. L. Round ligament. S. Sacral articular sur- 
face of sacro-iliac symphysis. P. Pubic symphysis, articular surface, a. 
Pyriformis muscle, b. Gluteus maximus muscle, c. Obturatococcygeus 
muscle, p. Spine of the ischium, f, f. Psoas muscles, g. Linea alba. 
h, h. Ureters, i, j, k, 1, Trunks of sacral nerves resting on the pyriformis 
muscle, m. Obturator nerve, q. Peritoneum covering the transversalis 
fascia. 



166 



GYNECOLOGY. 



obturator fascia. It gives off the following branches: The in- 
ferior hemorrhoidal ; the transverse perineal ; the superficial per- 
ineal or vulvar artery, which is much larger than the corre- 
sponding branch in the male — the artery of the bulb ; the profundi 
branch to the crus clitoridis ; and the dorsal artery of the clitoris. 
The round ligament receives a small branch from the epigastric 
artery, which anastomoses with the branch from the ovarian. 
The venous distribution of the pelvis is very abundant, and occurs 





Fig. i3( 



-Distribution of the Pudic Artery to the Structures of the Perineum. 
— (Deaver.) 



in the form of numerous plexuses, which freely communicate 
with one another. These veins are provided with valves. Con- 
sequently hemorrhage from an injured part will be very profuse 
when the whole pelvic vascular system is engorged, as, for 
instance, during pregnancy. Dissection discloses a. vesical plexus 
which lies external to the muscular coat of the bladder. At the 
lower part of the rectum the hemorrhoidal plexus is found 



ANATOMY. 



167 



situated beneath the mucous membrane. The distribution of 
the veins of the labia is similar to that of the arteries. From 
the superficial portion they drain into the pudic, which com- 
municates with the common iliac vein. The large veins from 
the labia minora open into the pars intermedia above. The 
blood returns from the glans and corpus clitoridis through the 
dorsal vein of the clitoris, which communicates with the vesical 




Fig. 131. — Relation of the Urethral and Vaginal Venous Plexuses with the 
Veins of the Clitoris and Bulb. The Right Side of the Pelvis Removed 
by a Section in Front, through the Pubic Body, About an Inch from the 
Symphysis, and. Behind, through Sacro-iliac Joint. — (Savage.) 

B. Bladder partially inflated, and b (vis), ureter cut just before it enters the 
bladder. V. Vagina distended. P. Section of pubis. R. Rectum. C. 
Clitoris. S. Sacrum, i. Bulb. 2. Its urethral venous process. 3. Lower 
efferent veins. 4. Dorsal vein of the clitoris. 5. Urethral venous plexus. 6. 
Commencement of vaginal venous plexus. 7, 8, 9, 10. Sciatic and gluteal 
veins corresponding to arteries. 11. Uterine veins assisting to form the 
uterovaginal venous plexus. 12. Obturator vein. 13. Internal iliac vein. 
a. Pyriformis muscle, b. Larger sciatic ligament, c. Pubo-, obturato-, 
and ischio-coccygeal muscles, d. Suspensory ligament of the clitoris, 
e. Bulbovaginal gland. /, /, /. Roots of sacral plexus of nerves. 



plexus. The vaginal plexuses are situated, one in the submucous 
tissue, and the other external to the muscular coat. They com- 
municate with the hemorrhoidal and vesical plexuses, receive the 
blood from the veins of the bulb, and empty into the internal 
iliac vein. The uterine plexus is very complex, and empties into 
the ovarian veins. The right ovarian vein enters the inferior 



168 



GYNECOLOGY. 



vena cava; and the left, the left renal vein. The right ovarian 
vein has a valve where it pierces the coat of the inferior vena 
cava, while the left has none. To this arrangement is attributed 




17 
14 



Fig. 132. — Veins and Erectile Venus Plexuses of the Female Pelvis. — (Savage.) 
B. Bladder. R. Rectum. L. Round ligament. U. Uterus. O. Ovary. V. 
Vagina. S. Sacro-iliac articulation. K. Kidney. T. Fallopian tube. 
P. Pubic symphysis, a, Pyriformis muscle, b. Gluteal muscles. c. 
Ischiococcygeus muscle, d. Internal obturator muscle, e, e. Psoas 
muscles, f. Linea alba, g, g. Ureters, h. Obturator nerve, i. In- 
ternal inguinal ring, site of canal of Nuck. i. Abdominal aorta. 2. 
Inferior mesenteric artery. 3, 3. Common iliac arteries. 4. External 
iliac artery. 5. Vena cava. 6. Renal veins. 7, 7. Common iliac veins. 
8. External iliac vein. 9. Internal iliac artery. 10. Gluteal. 11. Ilio- 
lumbar. 12. Sciatic. 13. Pudic. 14. Obturator. 15, 16. Epigastric 
veins. 17. Uterine vein. 16. Vaginovesical venous rete. 19. Spermatic 
veins. 20. Bulb of the ovary. 21. Vein to round ligament. 22. Fallo- 
pian veins. 



ANATOMY. 



169 



the greater frequency of pain and disease in the left ovary. The 
ovarian or pampiniform plexus lies between the folds of the 
broad ligament and communicates with the uterine plexus. The 
ovarian plexus opens into the inferior vena cava. At the hilum 
of the ovary is situated the collection of veins known as the 




Fig. 133. — Erectile Organs and Veins of the Female Perineum. — (Savage.) 
g. Crura clitoridis. i, 2. Bulb of the vagina. 3. Vestibular intercom- 
municating branches. 5. Superficial perineal and obturator veins. 6. 
Veins of communication with superficial epigastric veins. 8, 9, 10. Pudic 
vein and primary branches. M. Urethral orifice or meatus. V. Vaginal 
aperture. A. Anus. T. Tuberosity of ischium. O. Coccyx. G. Vulvo- 
vaginal gland. 



bulb of the ovary. The vesical, hemorrhoidal, and vaginal 
plexuses, with the pudic veins, empty into the internal iliac 
vein, which joins the inferior vena cava. From the hemorrhoidal 
plexus there is a communication with the portal systemi through 
the superior hemorrhoidal vein. 



170 



GYNECOLOGY. 



210. The Lymphatic System. — This comprises: first, the 
lymphatic glands; second, the lymphatic vessels. The lymph- 
atic glands are: (A) the inguinal glands, which lie parallel to 
and just below Poupart's ligament ; (B) the pelvic glands. (Fig. 




Fig. 134.— The Lumbo-iliac Lymphatics and Glands. Lymphatics of the 

Gravid Uterus and Appendages. — (Savage.) 
1,2. Superior lumbar glands. 3. Inferior lumbar glands. 4. Sacral lymphatic 

glands. 5. External and internal lymphatic glands. 6. Common iliac 

glands. 5, 7. Spermatic lymphatic plexus, a. Left renal vessels, b. 

Left renal vein. c. Left spermatic vein. d. Left spermatic vessels, 

covered by their lymphatic plexus, e. Aorta, f. Common iliac trunks. 

g. Ascending cava. h. External iliac artery and vein, m, n. Ureters. 

o. Right common iliac vein. p. Iliacus muscle, s. Psoas muscle. O. 

Ovary reversed, showing lymphatics between it and its bulb. 



134.) These comprise: (a) a gland situated as the isthmus uteri ; 

(b) the hypogastric or iliac glands, which lie beneath the perito- 
neum, in the space between the internal and external iliac vessels ; 

(c) the sacral glands, situated on the lateral aspect of the anterior 



ANATOMY. 171 

surface of the sacrum and the mesorectum ; (d) a gland or small 
collection of glands at the obturator foramen, known as the 
obturator gland of Guerin. All these glands discharge into the 
lumbar glands, Avhich lie in front of the lumbar vertebrae, and 
finally into the thoracic duct. The lymphatics of the external 
genitals form an extensive network on the internal aspect of 
the labia majora, over the labia minora, around the vaginal and 
urethral orifices, the vestibule, and the clitoris, and all these 
discharge into the inguinal glands. As a consequence, syphilis 
or cancer affecting the vulva or lower fourth of the vagina causes 
involvement of these glands. In the upper three-fourths of the 
vagina and cervix uteri the lymphatics open into the hypogastric 
glands. This is true not only of the lymphatics of the upper 
three-fourths of the vagina and cervix, but also of the lymphatics 
of the bladder. The lymphatics of the uterus pass through the 
broad ligaments with those of the ovary and tube and enter 
the lumbar glands. Some of the uterine lymphatics pass along 
the round ligaments to the glands of the groin. Leopold, in 
investigating the lymphatics in the unimpregnated uterus, re- 
gards the mucous membrane of the organ as a lymphatic surface 
consisting of lymph-sinuses covered with endothelium. The 
lymph passes from these spaces into the vessels of the muscular 
coat, and flows into the larger vessels which enter the broad 
ligaments. The distribution of these vessels and their extensiA^e 
character account for the rapidity with w^hich septic matter 
is absorbed from the uterine cavity and explain the various 
routes by which bacteria can pass through lymphatic canals or 
penetrate the blood-vessels. 

The lymphatics of the rectum lie in the mucous and muscular 
layers and communicate with the glands of the mesorectum or 
the sacral glands. 

Nerves. — The nerves distributed to the pelvic organs are 
derived from the spinal and sympathetic. The branches from 
the spinal nerves consist of the inferior hemorrhoidal branch of 
the pudic from the fourth and fifth sacral, and of the coccygeal 
nerves. These nerves supply the levator ani, sphincter, and 
coccygeus muscles ; the muscles of the perineum and clitoris are 
supplied by branches from the internal pudic, which nerve ter- 
minates in the nervous plexus of the glans clitoris. (Fig. 135.) 
The hypogastric plexus, derived from the sympathetic, lies be- 
tween the common iliac arteries, and distributes branches, which 
are reinforced by others from the lumbar and sacral ganglia 
and sacral nerves, to form the inferior hypogastric plexuses, 
one of which is situated on each side of the vagina. These 
plexuses distribute filaments to the vagina, uterus. Fallopian 
tube, and ovary. The pelvic, splanchnic, and hypogastric 



172 



GYNECOLOGY. 



nerves are motor and sensory to the bladder ; the pudic is motor 
to the sphincter; and all the nerves of the vagina and clitoris 
are sensory to the skin of the perineum, and especially so to the 




//. 



Fig. 135. — Nerves of the Unimpregnated Uterus with the Nerves of the CHtoris, 

— -(Savage.) 

I. Hypogastric plexus. 2. Rectal branch of inferior mesenteric plexus. 3. A 
lumbar ganglion of the sympathetc. 4. Spermatic plexus, supplies Fal- 
lopian tube, ovary, and part of the uterus. 5. Branches from third and 
fourth sacral, aiding to form 6, 7, right inferior hypogastric plexus. 8, 
Uterine filaments. 9. Vesical plexus and branch. 10. Trunk of great 
sacrosciatic nerve. 11. Muscular branch of the fourth sacral nerve. 12. 
Trunk of pudic nerve. 13. Continuation of 12 into dorsal nerve of the 
clitoris. R. Rectum. U. Uterus. B. Bladder. D. Transversus perinei 
muscle cut across. S. Section of ilium. P. Section of symphysis. 



ANATOMY. 173 

mucous membrane of the glans clitoris. The terminal filaments 
in the .uterus are found in the nuclei of the unstriped muscle. 
Those of the mucous membrane are said to end in the ganglia. 
End-bulbs have been found in the clitoris and vagina. In the 
ovary the nerves pass to the Graafian follicle and to the walls 
of the membrana granulosa. 

211. Consideration of the Pelvic Organs and Structure 
Studied as a Whole. — In the upright position the plane of the 
brim of the pelvis is at an angle of 60 degrees to the horizon. 
The fundus of the uterus lies just below this plane, with its 
axis at right angles to it, and consequently at right angles to 
the vagina, which is parallel to the brim of the pelvis. In 
the upright position the internal abdominal pressure is directed 
against the symphysis and the posterior surface of the fundus 
of the uterus when in its normal situation. 

The uterus, as we have seen, is freely movable — swung 
in its position in the pelvis by the ligaments. The broad liga- 
ments maintain it in the center of the pelvis, and by their position 
and relation serve to assist in maintaining it in an antefiexed 
position. The round ligaments are an additional stay, and 
when of normal resiliency, draw the fundus forward. The 
other ligaments are the uterovesical and the uterosacral. The 
former are formed by the reflection of the peritoneum from 
the bladder to the uterus; the latter, while consisting of folds 
of peritoneum, also contain muscle-fibers, which are derived 
from the superior muscular layer of the uterus. The function 
of the latter filaments is to hold back the cervix, while the 
intra-abdominal pressure maintains the fundus forward. De- 
viations from the normal inclination of the pelvis, from the 
normal resiliency and tone of the ligaments, from the proper 
relations and support of the vagina, increase in the weight 
of the uterus, and increased intra-abdominal pressure, are all 
factors in the production of uterine displacements, especially 
that form characterized by descent. The plane of the outlet 
of the pelvis when the patient is erect forms an acute angle 
in front Avith the horizon. The urethra, the vagina, and in 
the upper part of its course the rectum, are parallel to the 
plane of the brim of the pelvis. The lower portion of the rectum 
turns acutely bacl^rward and forms an axis at right angles to 
that of the vagina. This portion, the anus, looks backward 
and downward; consequently, the introduction of the finger 
or of the nozle of a syringe must be directed forward and up- 
ward, or directly toward the vagina, and after passing into 
the anus, is carried upward and baclavard. On median vertical 
section the vagina will be seen to be a mere slit, slightly S- 
shaped, the loAver part of which presents the convex surface 



174 GYNECOLOGY. 

of its posterior wall anteriorly. The pelvic floor is consequently 
divided into two segments, the anterior and upper of which 
rests upon the more fixed posterior segment. The rectum 
at the anus is found to form an anteroposterior slit. 

Intra-abdominal force first causes pressure of the anterior 
segment upon the posterior, and then a sliding backward of 
that portion of the inferior segment in front of the anterior 
wall of the rectum. 

PHYSIOLOGY. 

212. Functions. — The important functions of the genital 
organs are the processes associated with reproduction. These 
comprise the alterations in the organs by which menstruation 
is established, repeated monthly, and finally discontinued; 
'{he relation of the sexes in copulation; the fecundation of the 
ovum, its subsequent nutrition, and the procedure by which 
the matured product attains a separate existence. 

1. The transition from child to woman, indicated by the 
appearance of menstruation, is denominated puberty. 

2. The completion of development, which fits the individual 
for the processes of maternity, is called nubility. 

3. The deposit of the vitalizing principle of the male within 
the body of the female occurs through the act of copulation, 
and its union with the ovum is known as fecundation. 

4. The nutrition of this vitalized structure and its subse- 
quent course of development are recognized as gestation. 

5. The processes by which the matured product is afforded 
a separate existence are known as parturition. 

The first three of these divisions and their variations from 
the normal comprise the field of gynecology. 

213. Puberty. — The completion of the developmental pro- 
cess that results in the establishment of menstruation and 
ovulation, has been called puberty. It marks the transition 
from the child to the woman, and occurs between the thirteenth 
and fifteenth years. The age of the individual differs under 
varying circumstances. Puberty occurs earlier in the natives 
of hot climates than in those of the north, and earlier in the 
Latin races than in the Anglo-Saxon. Cit}^ girls mature at an 
earlier age than those raised in the country, and those raised 
in afiluence sooner than the poor. The occurrence of the pheno- 
mena of menstruation prior to the age of thirteen is called 
precocious puberty. Such instances are not infrequent. Iso- 
lated cases occur in which it appears at a very early age. Rein 
reports the case of a girl of six years whose pubes were covered 
with hair and who menstruated regularly for a year. The 



PHYSIOLOGY. 175 

''New York Medical Record," i6, xi, 1895, presents a report 
of a girl who gave birth to a child when ten years of age. 

Retarded or delayed puberty is caused by chlorosis, plethora, 
or some congenital condition of the genital tract. Numerous 
cases are recorded where women have given birth to children 
without the establishment of menstruation; in other words, 
ovulation occurs without the usual manifestation. 

The advent of puberty is manifested by other characteristics 
than menstruation. The figure becomes more rounded, from 
an increase of adipose tissue. The breasts enlarge and fre- 
quently become painful. Hair grows upon the mons veneris 
and labia majora. Under this process occurs increased blood 
formation, the development of glandular structure, particularly 
in the uterus and the mammary gland, and, especially, marked 
changes in the nervous system. "There is," Christopher 
Martin says, " a remarkable transformation in the psychic, 
emotional, and mental life of the girl. The current of her 
thoughts is mysteriously changed. Hopes and ^^earnings un- 
known before thrill and agitate her, and life acquires a new 
and deeper meaning. These profound and subtle changes 
are not so difficult to understand if we accept the view that 
puberty means the sudden bursting into activity in the midst 
of the nervous system of a hitherto dormant center." 

The glandular development of the mammas may be so rapid 
and at times so irregular as to simulate a tumor. The period 
of life should prevent error. 

214. Nubility. — The advent of puberty indicates that the 
conditions and functions are established that will permit pro- 
creation, but the structures are not sufficiently developed 
to render the individual suited for favorable reproduction. 
Experience has demonstrated that the mortality is much greater 
among those who come to the completion of gestation prior 
to the age of twenty. Women coming to early maternity 
mature early, reach the menopause at an early age, and are 
prematurely aged. 

215. Menstruation and Ovulation. — Menstruation — also called 
the menses, the monthlies, the courses, the turns, the sickness, 
and the, periods — has been defined by Sutton as the "periodic 
discharge of blood from the uterus, accompanied by the shed- 
ding of the epithelium of the body and fundus, as well as of 
that lining the utricular glands near their orifices." 

Ovulation is the discharge of an ovum from a matured Graa- 
fian follicle. These two processes are considered here in co-rela- 
tion, though we have no positive proof that they are co-depen- 
dent. We have, however, determinative evidence that they are 
occasionally independent of each other. The not infrequent 



176 GYNECOLOGY. 

occurrence of pregnancy prior to the advent of puberty and sub- 
sequent to the chmacteric is an indication that ovulation can 
occur without menstruation. Cases are recorded where a woman 
has had a number of children without menstruation ever having 
occurred. 

Menstruation, in the majority of women, occurs every twenty- 
eight days, and the flow lasts from two to eight days. The 
intervals may vary from twenty-one days to five or six weeks. 
It does not always occur at an absolutely definite date in the 
same individual. 

The quantity of blood lost is difficult to determine. The 
average amount is estimated at from three to five ounces. It 
has been mentioned that the flow varies in duration from two to 
eight days. A flow shorter than two or longer than eight days 
in duration indicates an abnormal condition. Absent or greatly 
decreased flow is known as amenorrhea. The prolonged or ex- 
cessive flow is called menorrhagia. When the function is asso- 
ciated with severe pain, it is pronounced dysmenorrhea. The 
menstrual discharge is not pure blood, but consists of blood- 
corpuscles mixed with mucus and desquamated uterine epithe- 
lium. In ordinary conditions it is a bright fluid, but when the 
flow is excessive or rapid, it comes away in large and dark clots. 

The duration of menstrual life is nearly thirty-five years, 
and, like its advent, the period of final cessation may be ad- 
vanced or retarded by various causes. 

Menstruation occurs only in women and in certain monkeys ; 
it is apparently limited to those animals that maintain the erect 
position. 

The flow is generally preceded by some premonitory symp- 
toms — a sense of weight, pressure, or uneasiness in the pelvis 
and back, and extending down the limbs. Mental and nervous 
irritability are frequently marked. Special nervous character- 
istics are exaggerated during, and especially immediately pre- 
ceding, the flow. The mental equilibrium is frequently dis- 
turbed, and women exhibit delusions during menstruation who 
are perfectly rational during the intervals. Epilepsy, migraine, 
and other nervous manifestations are prone to occur or to be 
exaggerated during or near the period. 

During the menstrual process the uterus and pelvic viscera be- 
come engorged with blood; the uterus is enlarged, turgid, and 
sensitive; the capillaries rupture, some upon the surface and 
others within the mucous membrane. The uterine epithelium be- 
comes desquamated ; during the process of engorgement the glands 
have become filled with epithelium, which is discharged from 
the external portion of the gland. Many of the cells are lique- 
fied, increasing the quantity of mucus. With the establish- 



PHYSIOLOGY 



177 



ment of the flow the engorgement is relieved and the general 
disturbance subsides. After the termination of the period 
the mucous surfaces are gradually regenerated from the epi- 
thelial tissue remaining in the glands, until at its culmination 
the process is again renewed. According to Napier, this des- 
quamation and regeneration of the structures from the utri- 
cular glands, and the accumulation of glandular products in 
the uterine glands and the ovaries, stands in a causative relation 
to menstruation. 

It is only when the ovaries and utricular glands attain a 



?6?c^ 



tf!'^^ 



.r^<'^^, --•^" 















0~Q;^ 



^^ t-^ 











Fig. 136. — Changes of Uterine Mucous Membrane During Menstruation. 

(Wyder.) 



development that renders their secretion capable of exerting a 
dominating influence upon the general economy that puberty 
occurs, and the process continues until these structures begin 
to atrophy and cease to exert their governing course. Napier 
denies the probability of the period being induced by ovulation, 
and cites the occurrence of the latter without menstruation, 
and the continuation of menstruation after the removal of 
both ovaries, as presumptive evidence. Many other theories 
are advanced for the periodic occurrence of menstruation. 
Johnstone believes in a special menstrual nerve plexus, situated 
12 



178 GYNECOLOGY. 

near the cornua of the uterus; but this structure has not been 
recognized by any other observer. 

My observation leads me to doubt that menstruation occurs 
after the complete removal of ovarian stroma. An occasional 
discharge of blood does not constitute menstruation. The 
pressure of the ligature upon the nerves of the ligament will 
cause a bloody flow a few days subsequent to removal of both 
ovaries, though the operation had been preceded a few days 
by the regular menstrual discharge. Doubtless a continued 
irritation may be a cause for other discharges. The removal 
of the appendages by the use of the Staffordshire knot or the 
simple transfixion of the pedicle and its ligation in two portions 
is prone to leave some of the ovarian stroma upon the stump, 
and menstruation will recur until the retained stroma is ex- 
hausted. 

The alteration of the uterine mucosa which occurs during 
menstruation prepares it for the reception and nutrition of 
the fecundated ovum. The fact that gestation occurs with- 
out an intervening period is no contravention of this supposition, 
but only a demonstration that the preparation can occasionally 
occur without the shedding of blood. 

The nerve influence leading to the increase of the liquor 
foUiculi, and the liquefaction of the cells of the membrana 
granulosa, promotes the multiplication of cells in the mucosa, 
Avhich is followed by menstruation. The coexistence of these 
processes is seen in the formation of a corpus luteum syn- 
chronous with menstruation. The course of menstruation is 
averted by pregnancy. Menstruation continues during pregnancy 
only with the rarest exceptions, and the functional activity 
of the ovaries is suspended during lactation. Neither ovulation 
nor menstruation is likely to occur during lactation. Many 
women prolong the period of lactation for the purpose of render- 
ing themselves less susceptible to fruitful coition. 

216. Menopause.— The conclusion of menstrual activity is 
recognized as a critical period in the woman's existence. It is 
variously denominated the menopause, the climacteric, and the 
change of life. The menstrual life of the woman lasts, upon an 
average, nearly thirty-five years, so that the menopause should 
occur between the forty-seventh and the fiftieth years. Its 
occurrence may be accelerated or retarded by various causes. 

Premature menopause occurs prior to the age of thirty-two, 
and may be induced by shock, severe illness, prolonged anxiety, 
overstudy, mental affections, disease of the ovaries, — such as 
destruction of the ovarian stroma by double ovarian tumors, — 
sepsis, chronic disease of the appendages, and some forms of 
metritis. 



PHYSIOLOGY. 179 

Early menopause occurs between the ages of thirty-two and 
forty -two. It occurs early in the virgin, and earlier in blonds 
than in brunets. Fat women reach the menopause early. A 
rapid increase in adipose tissue is associated with some cases of 
premature menopause. Occasionally the menopause occurs at 
an early age without any assignable cause. 

Retarded or Delayed Menopause. — The occurrence of the meno- 
pause is distinctly affected b}^ heredity. 

It may be delayed by child-bearing, by the presence of uterine 
gro^\1:hs, and by the presence of malignant degeneration. Rob- 
ertson reports the case of a woman who ceased to menstruate 
for twelve months at the age of fifty, when the flow returned 
and continued until her death at seventy. Saxonia speaks of a 
nun who had a return of her menstruation at the age of one hun- 
dred, which continued regularly until she died three years later. 

The term menopause is employed to designate the period of 
the change. The average duration of the menopause is about 
two and one-half years. A few fortunate persons continue to 
menstruate regularly until a certain period, when the flow dis- 
continues, never again to recur. Others continue irregular for 
six months, when it ceases. Generally a patient will notice that 
the periods are getting more scant, until finally she misses one 
or two periods; then menstruation recurs for a while, to again 
subside, thus continuing irregularly for one or two years. The 
irregularity may be prolonged over a period of four or five 
years. While, as a rule, the intervals are longer, the periods 
may occur more frequently, with intervals of but twenty-one, or 
even fourteen days. 

The flow may be increased, and occasionally hemorrhages 
occur without any assignable cause. 

Excessive or prolonged bleeding should always be a cause of 
anxiety, and should lead to a careful examination in order to 
determine its cause. The cause should not be assigned to change 
of life until careful investigation has eliminated every other 
source. The occurrence of menstruation is attended with the 
elimination of certain materials from the blood. 

Chemic changes in the blood and tissues are constant, and the 
elimination of the albuminoids during menstruation is demon- 
strated by a more marked alteration of the blood following 
menstruation than the mere blood-loss would produce. 

When menstruation is arrested by anemia or pregnancy, we 
see in the skin marked deposits of pigment and other materials 
that would be eliminated by its occurrence. 

When the menopause occurs suddenly, the retained products 
produce an intoxication which results in various nervous per- 
versions. It is a very usual occurrence to witness various vaso- 



180 GYNECOLOGY. 

motor disturbances, such as sudden sensations of heat; flushings; 
waves of blood rolHng up to the face, accompanied by a sensation 
of giddiness, suffocation, or oppression; cold, clammy perspira- 
tion ; shooting neuralgic pain ; headaches ; fullness of the vessels 
of the head and neck ; palpitations ; gastric irritation ; diarrhea ; 
irritability of temper; melancholia; and disturbed mental bal- 
ance. 

In sudden production of the climacteric after radical opera- 
tions the vasomotor disturbances are frequently so distressing as 
to render the condition for which the operation was performed 
preferable. 

Treatment. — The more distressing vasomotor disturbances can 
be ameliorated by the employment of tonics, good food, rest, 
massage, and the application of the galvanic and Faradic cur- 
rents; the administration of the bromids, asafetida, and other 
nerve sedatives ; the regulation of the bowels ;■ and the promotion 
of digestion. 

Picrotoxin in -g^-Q-grain doses three times daily seems to exert 
a specific influence in some cases. 

217. Copulation is that act of union of individuals of the 
two sexes by which the vitalizing principle of the male is depos- 
ited in the genital organs of the female. The sexual desire of 
the woman is much less marked than that of the man. Fre- 
quently she has no sexual sensation, and the act is even repug- 
nant, but she yields to the man's embrace from her wish to 
gratify his desire. Such a woman, mated to a man of impetuous 
inclination, often becomes a sexual slave. The clitoris and the 
tissues about the vestibule are erectile, and take part in the 
orgasm, during which a secretion is ejected from the vulvo- 
vaginal glands. 

Imperfect or unsatisfactory copulation is a prolific source of 
disease. Efforts to avoid the legitimate results of copulation, 
like all violations of nature's laws, visit their penalty upon both 
the offenders, but most heavily upon the woman. 

218. Fecundation. — The union of the spermatozoid with the 
ovum and the successful fertilization of the latter are known as 
fecundation. Its occurrence does not require that the woman 
should share in the pleasurable sensation of copulation; indeed, 
it can follow in spite of the fiercest resistance upon her part. 
The spermatozoids, the active fertilizing agent from the man, 
require no assistance from the woman, but by a vermicular 
motion can make their way to the ovum in the internal organs. 

There has been much discussion over the probable point 
at which fertilization occurs and as to the ability of the sper- 
matozoa to penetrate the narrow isthmus of the Fallopian 
tube against the waving cilia, the function of which is to pro- 



MALFORMATIONS. 181 

mote a current toward the uterus. The demonstration that 
they do overcome these obstacles in the sheep and other lower 
animals, and are found swarming over the ovary, and the fre- 
quent occurrence of ectopic gestation in the woman, should 
be accepted as a sufficient demonstration that they make the 
\^oyage. It is most probable that fecundation results in the 
tube, from which the vitalized ovum passes into the uterus, 
which is prepared for its reception. 

Impregnation is more likely to occur during or immediately 
following menstruation; less likely, immediately preceding the 
flow ; and the woman is least susceptible in the mid-interval. 

Independent of organic conditions, there is a marked differ- 
ence between individuals as regards their susceptibility to im- 
pregnation. 

MALFORMATIONS. 

219. Classification; Definition. — A genital malformation is 
any deviation from the normal form and structure of the fe- 
male reproductive organs. As the processes of development 
are not completed until puberty, such deviations may arise 
from the arrest or distortion of growth at any one of the periods 
we have already considered in the study of the formation of 
these organs. As the majority of instances of abnormality 
are due to prenatal causes, they are justly considered, there- 
fore, as congenital. In the former edition I considered the 
various lesions of parturition under the head of acquired mal- 
formations, but will now discuss them under the designation 
of traumatisms. 

220. Bifidities. — The development of the uterus and vagina 
from the coalescence of the two Mullerian ducts naturally 
leads, upon arrest or faulty continuation of the process, to a 
partial or a complete separation of these organs into two canals. 
Such a bifid development may be either equal or unequal. 
This double development may result in the formation of two 
canals by .a simple partition or septum through what seems 
one body, or a partial or complete separation into two bodies. 

221. The Degrees of Division. — The most frequent form 
of malformation is the presence of a more or less complete 
septum between the two sides of the uterus and vagina. This 
partition or septum in the uterus may, according to its extent, 
consist of five degrees. The first (I, Fig. 137) will present 
a mere outline which projects from the fundus. Such a con- 
dition is rarely recognized during life, unless opportunity is 
afforded for digital exploration of the uterine cavity. In the 
second degree (II, Fig. 137) a septum extends through the body 



182 



GYNECOLOGY. 



to the internal os. This form can be recognized following 
delivery or abortion, but otherwise may give no indication of 
its presence. The occurrence of pregnancy may cause its 
destruction. In the third degree (III, Fig. 137) the body and 
cervix are divided by the septum into two distinct canals. 
The fourth degree (IV, Fig. 137) affords a septum, which is 
incomplete only in the vagina, and the fifth (V, Figs. 137 and 
145) presents a complete uterovaginal septum, forming two 
canals. The one canal may be readily overlooked, or coition 
may occur in either side indifferently. 

222. Double Uterus, — The division of the organ into two 





Fig. 137. — -Degrees of 
Division of the 
Genital Tract. 



Fig. 1 38. — Uterus Bicornis. 



portions may be more or less complete, and consequently may 
form three classes : 

First, the division of the fundus by a groove and two lobes, 
known as the uterus bilobularis, uterus bicornis arcuatus, or 
uterus bicornis unicollis (Fig. 138), the latter especially when 
but one cervical canal exists (Fig. 139). 

Second, the body divided into two distinct portions, the 
double uterus bicornis (Barnes), uterus bifidus; it may have 
a single or two cervical canals (Fig. 140). 

Third, two separate organs exist, each with one tube and 
ovary, uterus didelphys (Fig. 141). The bodies diverge, each 



MALFORAIATIONS. 



183 



half being held to the corresponding side by the short broad 
lisrament. 




Fig. 139. — Uterus Bicornis Unicollis. 




Fig. 140. — -Uterus Bifida. 



223. Unequal Development of the Two Sides. — The two 

canals of Mliller may be incompletely developed, and thus 



184 



GYNECOLOGY. 



produce asymmetric organs of varying form. The one canal 
may be completely atrophied, while the other presents a well- 



-^/h, 



- \ 



Fig. 141. — Uterus Didelphys. 

developed horn — the uterus unicornis (Fig. 142). Generally, 
the absence of one horn is associated with absence of the corre- 
sponding tube and ovary. The horn may be rudimentary 




Fig. 142. — Uterus Unicornis. 



or partly developed, permitting the occurrence of menstruation 
and even pregnancy. Such a horn is not prepared for the 
maintenance of the fecundated ovum to the completion of 



MALFORMATIONS 



185 



gestation, and will result in rupture prior to the sixth month. 
The occurrence of such a pregnancy is quite as dangerous to 
life as a tubal gestation, from which it can not, previous to 
operation, be differentiated. Atresia in the canal of a rudi- 
mentary or partly developed horn may exist, and lead to an 
accumulation of the menstrual secretion and the formation 
of a tumor (Fig. 143). The diagnosis of such a condition is 
exceedingly difficult, and can be determined only during an 
operative procedure. The accumulation may rupture into 
the vagina, but usually at such a height as to leave a portion 
of the sac dependent and 
undrained, and, there- 
fore, likely to become 
infected and lead to sep- 
ticemia. When the con- 
dition is recognized, the 
treatment should be that 
for retained menstrua- 
tion, which will be de- 
scribed later. The de- 
velopment of a one- 
horned uterus may be 
associated with a double 
cervical canal, - — uterus 
biforts, — a condition 
which may cause embar- 
rassment during labor. 
The septum when dis- 
covered may be pushed 
to one side, or, if neces- 
sary, be cut between two 
sutures ( Pozzi ) . When 
torn, it has caused severe 
hemorrhage. 

224. Absent Uterus. — Entire absence of the uterus is rare, 
and is almost always associated with absence of the other genital 
organs, particularly of the vagina. The determination of the 
condition is difficult. 

The introduction of the index-finger of one hand into the 
rectum, and that of the other or of a catheter into the bladder, 
enables the operator to thoroughly explore the pelvis. Failure to 
recognize the organ may be due to its rudimentary condition or 
its displacement to one side, and we can assert its entire absence 
only when we have been able to explore the pelvis through an 
abdominal incision or during an autopsy. 

225. A rudimentary uterus may exist in the form of a slight 




Fig. 143. — Atresia of Rudimentary Horn with 
an Accumulation of Menstrual Blood. 



186 



GYNECOLOGY. 




thickening over the surface of the bladder, as two undeveloped 
canals in the form of a T, — the uterus bipartitus (Fig. 144), — 
when the vagina is frequently absent or may be partly developed, 
deepened by coition, or may exist as a small culdesac continuous 
with the urethra, which has been dilated by repeated efforts 
at coition. Menstruation is generally absent; ovulation may 
occur without molimina, or there may be the occurrence of 
hematometra. 

When the vagina is well developed and menstruation occurs, 
the condition may remain undiscovered. The rudimentary 
character of the organ can be determined by bimanual palpation 

or by palpation through the 
rectum and the bladder, as 
has been described. The oc- 
currence of painful molimina 
may require castration. 

226. Fetal and infantile 
uteri are instances in which 
the organ has been arrested 
during the fifth stage of its 
development. The uterus is 
small, the cervix two or three 
times the length of the body, 
and an acute anteflexion of 
the body probably exists. 

The infantile uterus dif- 
fers from the fetal in that the 
arbor vitcg arrangement of 
the mucous membrane no 
longer extends to the fun- 
dus. Menstruation rarely oc- 
curs, and sexual desire may 
be absent. The external 
genitals may be poorly or 
The breasts not infrequently are normally 




Fig. 144. — Uterus Bipartitus or Duplex 



well developed 
developed. 

Treatment. — The existence of a malformation is an indication 
of defective development and presents a condition in which 
the function of the affected organ must be more or less impaired. 

The presence of a septum through the uterus and vagina 
may be a cause of dyspareunia, due to the diminished size of 
the vaginal canal. It need not produce distress or danger during 
gestation, but not infrequently the cervical and vaginal septa 
may cause dystocia. 

The vaginal septum should be cut through its entire length 
and the edges of each wall sutured to prevent readhesion. The 



MALFORMATIONS. 



187 



cervical septum can be crushed by forceps, which should be 
left in place to produce necrosis of the compressed tissues. Such 
septa do not generally withstand the first gestation, but are 
broken down in the course of labor. I have twice seen a bridle 
of tissue attached to the lower portions of the anterior and 
posterior vaginal walls, which were without doubt remnants of 
an originally more complete septum. 

The division of the uterus into two equally developed por- 
tions does not usually call for treatment. The investigation of 
a large number of such cases demonstrates that pregnancy has 
frequently occurred without appearing to produce difficulty in 
parturition. This necessarily 
depends upon the develop- , _ 

ment of the separate cornua. 

In one patient upon whom 
hysterectomy was done for 
interstitial myomata, her his- 
tory revealed that she had 
given birth to two children, 
apparently without any un- 
usual phenomena. The op- 
eration disclosed that she had 
a rudimentary horn upon one 
side, which had its own cervi- 
cal canal and opened into a 
blind pouch for a vagina, 
which was situated between 
the existing vagina and the 
bladder. 

It is my purpose upon the 
next opportunity to split the 
adjoining cornua of a partially 
bifid uterus, and after coapt- 
ing their edges, suture the 

surfaces so as to establish one cavity. It may be questioned 
how such a reconstructed organ will endure the course of a ges- 
tation, but if pregnancy can go to full term in one horn of the 
uterus, the organ thus formed should be more capable of per- 
forming its physiologic functions. AVhere the uterine cornua 
are unequally developed, the danger is from conception occur- 
ring in the rudimentar}^ cornu. The recognition of the exist- 
ence of such a pregnancy should be considered ample justifica- 
tion for its extirpation by operation. Where both cornua are 
rudimentary, and the patient suft'ers from menstrual molimina, 
the abdomen should be opened, and the ovaries removed. Simi- 
lar advice is proper Avhen the uterus is absent. 




Fig. 145. — Uterus Biseptus. 



188 GYNECOLOGY. 

The fetal and infantile uteri frequently present conditions 
in which the function of menstruation is performed irregularly 
and attended with severe pain. The probability of the patient 
becoming pregnant and carrying the fetus to full term is depend- 
ent upon the degree of development. Under the stimulation of 
the marital relation such uteri occasionally increase in size. 
More frequently the individual complains of irregular and painful 
menstruation, and is sterile. 

227. Congenital prolapsus uteri is an exceedingly rare con- 
dition, and is usually associated with other forms of defective 
development, as spina bifida. 

228. Accessory or trifid uteri have been reported. Hollander, 
in 1894, found a second uterus lying in front of the normal organ, 
between it and the bladder. It was a simple cervix with two 
orifices, having neither adnexa nor round ligaments. Depage 
describes a trifid uterus which probably arose from a diverticulum 
of one of the ducts of M filler. 

229. Absent or Rudimentary Tubes. — -Absence of the Fal- 
lopian tubes is a rare occurrence, and is associated with a similar 
condition of the ovaries and uterus. The absence of one tube is 
of more frequent occurrence; a unicornate uterus is generally 
found. A rudimentary tube is generally the result of an attack 
of fetal peritonitis. The tube may be a simple cord and yet 
have well-developed fimbria. The fimbria may be independent 
of the openings. 

230. Accessory tubal ostia are frequent. Ferraresi found six 
openings upon one tube, all of which were surrounded by fimbria. 
These openings are generally near the end, but may occur near 
the middle of the duct. They are probably due "to failure in 
closure of the groove in the germinal epithelium or to splitting 
of the Miillerian duct after it has closed. 

231. Anomalies in Length. — The normal tube is from ten 
to twelve centimeters long; in ovarian or broad ligament cysts 
and in ovarian hernia one tube may be found from sixteen to 
eighteen centimeters long. 

232. Absent or Rudimentary Ovaries. — Absence of ovaries 
is an exceedingly rare condition, requiring an inspection of the 
abdominal cavity to confirm the suspicion. Absence of one is 
less rare, and is associated with a unicornate uterus, and occasion- 
ally with absence of the corresponding kidney. The rudi- 
mentary state is more frequent, and may be fetal or adult. It 
may contain no glandular tissue, or the presence of unclosed 
Pfliiger's tubes may lead to a suspicion of a testicle. The con- 
dition may be produced by oophoritis or peritonitis during fetal 
or adult life, or by the twisting of a pedicle. 

233. Supernumerary ovaries are very rare. Von Winckel 



MALFORMATIONS. 189 

found a third ovary in front of the uterus. Tufts of OA^arian 
stroma have been described. The occurrence of menstruation, 
and even of pregnancy, after the supposed removal of both 
ovaries has been reported, but it is more probable that in all 
such cases there has been failure to remove the entire structure 
of both glands. 

234. Accessory or constricted ovaries are more frequent. 
A portion of the ovary may depend from the main body by 
a more or less well-marked pedicle; as many as two or three 
have been found associated with one ovary. 

235. Displacements. — The descent of the ovary may have 
occurred, and the organ may be situated above the brim of 
the pelvis. The presence of the ovary in the sac of a hernia 
is a lesion often difficult of accurate recognition and productive 
of serious distress. 

236. Defects of Round or Broad Ligaments. — Absence of 
the round ligament is generally associated with absence of 
uterus in w^hole or in part. I saw one patient in w^hom the 
muscular structure of the round ligament was completely ab- 
sent. The fold of the broad ligament, in which the round 
ligament would lie, presented a thin, corrugated margin. The 
persistence of the canal of Nuck results in the formation of a 
hydrocele, which may attain to considerable size in the labia 
majora. The broad ligaments may be absent, extremely short, 
or unequal in length and thickness. They may contain cysts, 
which are relics of the parovarium. 

237. Complete Absence or Rudimentary Development of 
the Vagina. — In complete absence of the canal no trace of 
vaginal tissue Avill be found between the rectum and the bladder. 
These two organs lie in contact, with connective tissue only 
intervening (Fig. 146). In the rudimentary vagina a fibrous 
cord may exist, indicating the site of the ducts of Muller, the 
development of which has been arrested in an early stage of 
fetal life. We may have a complete absence of one of the 
segments of the vaginal canal, with an incomplete develop- 
ment of the other. In these cases of absent or rudimentary 
vagina the uterus is generally entirely absent or is reduced 
to a rudimentary nodule. In some patients normal ovaries 
are present without any manifestation of menstrual molimina. 
Occasionally, there are periodic pains at the times of ovulation. 
Cases have been reported of vicarious hemorrhages from different 
portions of the body, associated with extreme pains at the 
supposed menstrual periods, when a well-formed uterus was 
present. The vulva may also be absent, but is more frequently 
well formed, presenting a funnel-shaped depression behind 
well-developed nymphse. The hymen may be perfectly normal 



190 



GYNECOLOGY. 



and the urethra at times may be dilated by the efforts that have 
been made to effect coition. It is difficult to determine why it 
should be the lower portion of the vagina that most frequently 
exists in cases of arrested development. It is probably due to 
an abnormal elongation of the vestibular canal. This pouch, 
in the absence of the vagina and uterus, has been found to 
be two or three centimeters in length and sufficiently wide to 
admit the finger. These dimensions are very considerably 

increased by sexual ef- 
forts. The opening is 
generally closed by a 
pearly, reticulated mem- 
brane with a cicatricial 
appearance. The central 
portion of the vagina 
may be absent, or the 
two portions may be 
separated by a mem- 
brane of variable thick- 
ness, which at times is 
perforated. One patient 
came under my observa- 
tion in whom there was 
a membrane dividing the 
upper and lower halves 
of the vagina, and a 
small opening situated 
at one side, which per- 
mitted the menstrual 
discharge to escape. 
The incision of this 
membrane exposed a 
good-sized cavity above, 
and by cutting out a 
portion of this septum, 
the two mucous mem- 
branes of the upper and 
lower halves were su- 
tured together, to form a good-sized vagina. In patients with 
absent vagina the examination should be practised with a finger 
in the rectum and a catheter or a sound in the bladder. _ Com- 
bined rectal and vesical touch enables us to determine the 
presence of the uterus and its degree of development. 

Treatment. — Absence of all or a part of the vagina affords 
different indications according to the development of the uterus. 
If the latter organ is normal and the symptoms of menstrual 




Fig. 146. — Absent Vagina. 



MALFORMATIONS. 



191 



molimina have existed, with a uterus increased in size, the 
presence of hematometra should be suspected, and interference 
should be employed. If there is no uterus, and well-developed 
ovaries are present, associated with painful sensations, the 
condition may be considered a sufficient indication for cas- 
tration. Absent vagina renders the person sexually incom- 
petent, and it becomes a serious question as to w^hether a vagina 
shall be established for sexual purposes. The operation for 
the formation of a vagina Avas first performed by Amussat. 
The operation is performed by 
making an incision through the 
vulvar surface, using chiefly the 
fingers in the division of the 
soft parts, and proceeding step 
by step with tearing and dis- 
secting combined. The finger 
of the operator or of an assist- 
ant should be kept in the rectum 
and the sound in the bladder. 
These organs can be thus 
readily recognized and their in- 
jury avoided. When a depth 
of from six to eight centimeters 
has been reached, or the perito- 
neum opened, the second step of 
the operation should be per- 
formed, which is the investment 
of the funnel thus established 
with integument to prevent ci- 
catricial contraction. The skin 
and mucous membrane of the 
adjacent parts may be em- 
ployed for this purpose. When 
the labia minora exist, they may 
be split and utilized for the lin- 
ing of the anterior portion of the 
canal. (Fig. 147.) After the su- 
tures are applied the cavity is 

packed with iodoform gauze, and the packing is retained or 
renewed until cicatrization is complete, when the canal may sub- 
sequently be kept open by a glass plug. (Fig. 148.) In some 
cases attempts have been made to estabHsh cicatrization over a 
glass plug in the newly created canal, without any attempt to 
line, it with mucous membrane. Such a canal, however, is ex- 
ceedingly difficult to keep open, because it is Hable to contrac- 
tion even though an obturator is constantly worn. The lining 




# 



Fio- 



147 



—Line of Incision for For- 
mation of Flaps. 
2. Flaps from labia minora which 

are split and used to line the 

vas:ina. 



192 



GYNECOLOGY. 



of such a canal has been accompHshed by following the opera- 
tion by one upon another patient for redundant vagina, and 
utilizing the vaginal tissue removed to form a lining membrane 
for the newly created vagina. The tissue should be sutured 
over a glass plug (Fig. 149), or, preferably, over the end of a 
slightly distended bivalve speculum, which is introduced into the 

canal with the prepared 
hood of membrane, and 
as the speculum is with- 
drawn, some iodoform 
gauze is lightly packed 
through it, keeping the 
membrane in place. 
During the preparation 
of the vaginal lining the 
cavity should be packed 
with gauze, and the 
packing introduced with 
the hood should be re- 
moved at the end of a 
week. If the tissues by 
this time have united, it 
should be irrigated, re- 
moving any tissue which 
has not retained its vi- 
tality. 

In the patient repre- 
sented by Figs. 147 and 
148, after forming the 
wall of the anterior por- 
tion by splitting the 
labia minora, I trans- 
planted a flap from the 
posterior part of each 
thigh, which fortunately 
Fig. 148.— Flaps outlined in Fig. 147 Sutured became attached, and a 

very satisfactory vagina 
was formed. 

The lining membrane 
can be very much better secured by dissecting up a flap from 
the inner side of each thigh, which can remain attached to the 
posterior part of the vulva and thus be more certain of having 
its nutrition maintained (Fig. 148). 

In making the dissection for the vagina, no hesitancy should 
exist in opening through the peritoneum. By making such 
an opening the presence and size of a rudimentary uterus are 




148. — Flaps outlined in Fig. 147 Sutured 
in Place, and Denuded Surfaces which 
Have Furnished Flaps to Line Posterior 
Wall. 



MALFORMATIONS. 



193 




Fig. 149. — Sims' Glass Dilator. 



more readily determined and the latter organ affords a safe 
point for the fixation of the flaps to line the constructed vagina. 

238. Unilateral vagina is due to arrest of development in 
one of the ducts of ^Kil- 
ler, the other forming 
the vagina. Such a con- 
dition may be suspected 
when the canal is ex- 
tremely narrow. In cases 
of double vagina there 
may be incomplete devel- 
opment of one of the ducts. 

239. Double Vagina (Fig. 150).— In this condition the 
septum divides the entire vagina, \vhen the uterus is also double, 

or divided. Occasion- 
ally, the septum in the 
uterus does not extend 
through the external 
OS, while that of the 
vagina terminates be- 
low it. The hymen 
may have two open- 
ings, simulating double 
vagina. Coition gen- 
erally occurs through 
the larger of the two 
conduits; occasionally 
it takes place in either 
one. When the par- 
tition of the vagina is 
partial, the superior 
portion of the septum 
will be lacking. AVhen 
the uterus is double, 
the upper portion of 
the vagina is often 
found to contain the 
septum, while fusion 
has been complete be- 
low. The septum is 
usually thick and 
fleshy, resembling the 
rectovaginal partition, 
or it may be very thin, 
and even perforated in 
Partition of the vagina is not incompatible with normal 




"iK 



Fi< 



150. — Double Vagina. 
from patient of Dr. J 



-{Photograph taken 
M. Fisher.) 



places. 



13 



194 GYNECOLOGY. 

labor. Dunning has reported cases in which the two vagina were 
separated by a septum that began just above the vulva and 
extended to the interval between the two small cervices. The 
separation of the uterus into two parts was demonstrated by 
the use of the sound. Pregnancy occurred upon the right 
side, and as the uterus enlarged, the septum disappeared. Dur- 
ing labor the vaginal portion was torn from top to bottom 
and only the lower portion persisted. An incomplete septum 
may form an obstacle to the passage of the child's head. When 
it does so, it should be incised. In one patient under my ob- 
servation there had been a vaginal septum, which was de- 
stroyed during a previous labor, and there remained a bridle 
extending from the anterior wall of the vagina back to the 
posterior commissure, which hung below the vulva. Twice 
have I cut through the septum the entire length of the vagina, 
and sutured the surfaces on each wall, so that a single canal 
was formed. This course I considered wise, as it decreases 
the discomfort during coition and removes a cause of dystocia 
in the event of pregnancy. 

240. Atresia of the genital canal is either congenital or 
acquired. The latter will be discussed farther on in these 
pages. Congenital atresia may affect any portion of the canal, 
but is more likely to occur within the vagina or near its orifice 
at the junction of the vagina and vestibular canal. Next in 
frequency is the atresia of the internal or external orifices of 
the cervical canal, although the congenital closure of these 
orifices is comparatively not nearly so frequent as is the ac- 
quired. Vulvar atresia is not uncommon. It is produced 
by imperforation of the hymen or from agglutination of the 
labia minora or majora. In the latter there is usually an 
orifice in front through which the urine and menstrual flow 
can escape. Such conditions are often unrecognized until 
after the establishment of puberty, when the occurrence of 
periodic distress in the pelvis, colic -like pains, sensation of 
weakness, bearing down, and irritability of temper indicate an 
effort to establish the menstrual flow\ The continuance without 
discharge, and later the development of a tumor in the median 
line, should awaken the suspicion of the attendant to the pos- 
sibility of obstruction to the menstrual discharge and of its 
accumulation within the genital canal. The mere inspection of 
the parts discloses the imperforation of the hymen. (Fig. 151.) 
A tumor will protrude from the vulva; difficulty or abnormal 
frequency in micturition, more or less obstruction in evacuating 
the bowels is experienced, and a smooth, purplish surface is 
seen at the vulvar orifice. If the obstruction is situated in 
the vaginal canal, the vulvar protrusion will not be so marked. 



MALFORMATIONS. 



195 



The introduction of the finger into the canal, however, dis- 
closes the accumulation. It is more definitely determined by 
the finger in the rectum, when the globular tumor encroaching 
upon that organ is recognized. Pressure over the abdomen 
causes a sensation of elasticity or indistinct fluctuation. When 
the vagina is absent the accumulation forms in the upper part 
of the vaginal canal or within the uterine cavity. An accumu- 
lation in the vagina is known as a hematocolpos ; in the uterus, 
as a hematometra; in the Fallopian tube, a hematosalpinx; 
in both uterus and vagina, a hematocolpometra ; and when the 
distention also involves the tube, it becomes a hematocolpo- 
metrasalpinx. 

The symptoms are : absent men- 
struation, although the patient ex- 
periences each month discomfort, a 
sense of fulness, or engorgement in 
the pelvis with the usual nervous 
manifestations which awaken the 
anticipation that menstruation is 
about to make its appearance. A 
symmetrical enlargement of the 
lower abdomen appears, which 
from its contour has been mis- 
taken by the careless observer for 
pregnancy. The history of the 
case with a careful physical ex- 
amination of the patient should 
establish the diagnosis. When the 
obstruction occurs at the internal 
OS with a normal cervix and 
roomy vagina, the diagnosis be- 
comes more difficult. The mere 
fact that a girl has never men- 
struated does not exclude the 
possibility of pregnancy. In the 
latter will be found mammary 

changes, an enlarged and softened cervix, increased vaginal secre- 
tion, swelling, and a dusky appearance of the vagina and vulva. 
In the accumulation of blood these symptoms are absent and 
the cervix remains small, rather firm and hard. As the accumu- 
lation increases the cervix becomes softened, the uterus thinner, 
forming a thin-walled sac which affords distinct fluctuation. 

Treatment. — Operators were formerly very much averse to 
evacuating the fluid of such a collection. The fluid is thick, 
chocolate colored, and quite slimy, the latter due, of course, 
to the retention of the blood and mucous secretions of the canal. 




Fig. 151. — Imperforate Hymen. 



196 



GYNECOLOGY. 




bichlorid 
4000) or 
: 2000 to 
A large 
the solu- 
be em- 
irrigation 



It formerly was advised that a small pinhole orifice should 
be made through the opening in the hymen, to allow the dis- 
charge to continue slowly for several days. Such a procedure 
almost surely resulted in infection of the material and produced 
an inflammatory condition of the genital canal, which not in- 
frequently caused the death of the patient. The enormous dis- 
tention of the tissues renders them extremely anemic, and the 
femoval of the pressure naturally permits an engorgement, 
which can readily result in inflammation. The most satisfactory 
method of treatment, however, consists in a free incision to 
evacuate the contents of the cavity ; remove the stringy mucus 
with the finger and then thoroughly irrigate with a weak anti- 
septic solution, prefer- 
ably mild 
.-. ^ • ' \- solution (i : 

•"■* \' i ' formalin (i 

> . I : 1500). 

quantity of 
tion should 
ployed ; the 
to be followed by a 
douche of normal salt 
solution. Finally the 
cavity should be light- 
ly packed with iodo- 
form gauze to afford 
moderate pressure 
upon the surface, to 
prevent engorgement, 
and to give the struc- 
tures something upon 
which to contract. 
When the accumula- 
tion occurs above an 
obliterated or absent vagina, a trocar can be employed to reach 
the fluid, guided through the intervening structures with a finger 
in the rectum. The opening made by the trocar is then enlarged 
to permit a free evacuation and the treatment already advised 
should be employed. When the accumulation occurs in the 
uterus from obliteration of the external os, it will often be diffi- 
cult to determine the site of the latter. The cervix should be 
exposed, and, if we can not determine the situation of the former 
OS, a puncture should be made with the trocar, which opening 
should subsequently be enlarged in order to permit the evacua- 
tion of the uterine contents. The cavity is then irrigated and 
packed with gauze. If the obliteration has developed at the 



Hematocolpos. 



MALFORMATIONS. 



197 



internal os, the remaining cervical canal affords a passage 
through which the puncture can be safely made. The canal 
having been dilated, and the cavity thoroughly irrigated, the 
latter should be lightly packed with gauze. 

The one element of danger in these operations occurs when 
the Fallopian tube is distended with an accumulation and is 
fixed by extensive adhesions. The dragging upon the thin 
tube which occurs from the contraction of the empty uterus 
may cause its rupture and the escape of its contents into the 
peritoneal cavity. Extreme care should be exercised in a 
hematosalpinx not to make much pressure upon the abdominal 
surface while the sac is being emptied. Whenever the sac has 
disappeared with in- 
sufficient discharge 
from the uterus, or 
when it has disap- 
peared before the 
opening into the col- 
lection has occurred, 
an immediate abdo- 
minal incision should 
be made to cleanse 
the peritoneum and 
remove the offending 
sac. 

241. Lateral Atre- 
sia. — Atresia may 
take place in one- 
half of a divided va- 
gina or uterus. When 
it occurs in a portion 
of the vagina, a lat- 
eral tumor will pro- 
ject into the vaginal canal, which will be so elastic and obscure 
as to render doubtful the fact whether it is a pelvic cyst or a 
lateral hematocolpos. Such cases are less dangerous than atresia 
of the entire half of the vagina, as the accumulation will prob- 
ably rupture into and discharge through the existing vagina. 
The opening, however, will be high, permitting serious symptoms 
from infection and the development of a pyocolpos. It is gener- 
ally advised to make a free incision and pack such a cavity with 
iodoform gauze, but I much prefer to excise a large section of the 
wall and unite the mucous surfaces of its cut edges so that the 
two chambers become one. When the atresia has occurred in 
one-half of the uterus, the diagnosis is difficult. It is not always 
situated to one side of the developed horn, but may curve about 




Fi-. 



-Hematometra. 



198 GYNECOLOGY. 

it. The accumulation may then be accessible through the vagina, 
or may be exceedingly difficult to reach. When accessible, it 
should be opened through the vagina. When inaccessible 
below, the tumor should be removed by an abdominal incision, 
as for pyosalpinx. 

242. Absence of the vulva is generally associated with a 
similar condition of the vagina and uterus, although this de- 
fect may exist with a normal development of the other genital 
organs. It then probably results from coalescence of the 
labia major a. The latter are generally absent in exstrophy of 
the bladder, and may also be found so in other malformations. 
The nymphs can be absent and the clitoris so imperfectly 




Fig. 154. — Hematocolpometra 

developed that the site of the vulva presents a mere slit or 
flattened surface, upon which the urethral orifice opens. 

243. Infantile vulva is found in weak, sickly women, who 
have suffered from prolonged ill health prior to puberty, and 
is generally associated with an imperfect development of the 
uterus and tubes. The mons veneris and labia majora will be 
bereft of, or sparsely covered with, hair. 

244. Defects in Nymphae. — Absence of the nymphs is in- 
frequent, and is accompanied by incomplete development of 
the clitoris. More frequently they are thin, flabby, elongated, 
and pointed. Occasionally they are perforated by small open- 
ings. Hypertrophy of the nymphse is much more frequent. 
The nymphae project beyond the labia majora; in the Bush- 



MALFORMATIONS. 



199 




women of Africa they form large folds, which reach nearly to 
the knees, and are known as the Hottentot apron. 

245. Defects of the Clitoris. — The clitoris may be so enor- 
mously developed as to cause the sex of the individual to be 
questioned. In exstrophy of the bladder and absence of the 
symphysis it may be bifid or rudimentary. It is rarely absent. 
Frequently, from congenital conditions or from neglect of 
cleanliness, the smegma is retained beneath the prepuce, pro- 
ducing such irritation and 
adhesions that the glans '~ 

clitoris is compressed and 
prevented from attaining 
its normal size. The ad- 
hesions become so firm as 
to render their separation 
difficult. The existence of 
adhesions and the reten- 
tion of smegma are capa- 
ble of producing quite as 
marked nervous phenom- 
ena as the analogous con- 
dition in the male, some of 
which are: irritable blad- 
der, nervous disturbances, 
masturbation, absence of 
sensation, and convul- 
sions. The occurrence of 
such symptoms should 
direct attention to the 
clitoris as a possible 
cause. 

Treatment. — The glans 
clitoris should be thor- 
oughly exposed by push- 
ing back the prepuce. 
The adhesions can readily 
be broken up with a probe F^ 

or a grooved director. 

When the prepuce is so long as to form a hood and completely 
envelop the glans, it should be retracted by removing an elliptic 
piece of integument about half an inch above the clitoris, with 
the long diameter of the ellipse parallel to the cleft of the vulva. 
This denuded portion should be closed by sutures introduced 
in its long axis. The length of the denudation necessary de- 
pends upon the projection of the prepuce. The prepuce may 
be dissected awav and the cut edo:es sutured so that the dans 




.^^ 



-Enlari^cd Clitoris. 



s. 



200 GYNECOLOGY. 

subsequently remains exposed. A better procedure is to re- 
move the margin of the prepuce around the glans. The cut 
edges should then be united with catgut sutures. 

246. Defects of the Hymen. — The hymen is composed of 
tissue analogous to the corpus spongiosum in the male. It 
partly closes the vaginal orifice, and has upon its superior surface 
the foldings of the mucous surface of the vagina. It is generally 
crescentic (Fig. 99), with the concave margin anterior. It 
can present an annular opening (Fig. 100) ; two openings, sepa- 
rated by a septum (Fig. 103); or a number of openings (Fig. 
104) — the cribriform. It sometimes resembles in appearance 
the infantile form, when it is infundibuliform (Fig. 102), or its 
edges may be dentated (Fig. 10 1) or serrated. Its normal 
situation is just within the vulva, where it is exposed by sepa- 
ration of the labia. In the colored race its situation is higher. 
Its opening in the marriageable woman will easily admit the 
tip of the finger. Atresia has been described. (Section 240.) 
Supernumerary hymen have been reported, but these are prob- 
ably congenital bridles in the vagina. A congenital absence 
of the hymen must be questioned. The hymen is generally a 
thin membrane, which ruptures during the first coition (Fig. 105) 
and sloughs away after confinement, leaving as remnants the 
carunculae myrtiformes. The laceration may be central pos- 
terior, triangular, or stellate. After a single coition the torn 
surfaces may unite. I have seen two patients in whom the 
hymen was so firm as to form an actual barrier to coition, re- 
quiring incision to render the act possible. Cases are reported 
where it did not rupture during labor, or offered such an ob- 
stacle to delivery as to require incision. Its laceration is not 
usually attended with bleeding, but occasionally it is, however, 
followed by severe, and even dangerous, hemorrhage. 

Incision is made with bistoury or scissors, while the labia 
are widely separated. Two posterior lateral incisions are 
preferable to a single posterior. Hemorrhage, if severe, should 
be controlled by a vaginal tampon, or, preferably, by a suture. 

247. Hermaphroditism is a condition in which there is a real 
or apparent union of the two sexes in the same individual. 
True hermaphoditism has not been demonstrated in the human 
species, although a number of cases have been reported. The 
case represented in figure 156 presents characteristics of the 
two sexes, but, like other such cases, requires a microscopic 
examination to demonstrate the presence of both ovaries and 
testicles in the same individual. 

Pseudohermaphroditism is a condition in which there is 
such an apparent union of the sexual organs of the two sexes, 
or such a malformation, or defective development of the male 



MALFORMATIONS. 



201 



organs or excessive development of those of the female, as to 
render the determination of the sex of the individual during 
life difficult, if not almost impossible. Pseudohermapdroditism 




Fig. 156. — Apparent Hermaphroditism. — {" Aiiicncan Journal of Obstetrics.") 

is divided into mascuhne and feminine, according to the pres- 
ence of testicles or ovaries. The females resembling men 
form a class known as the gynandria, while the man resembling 
the female is classed as an androevnus. 




Fie 



-External Genital Organs of Madame Le Fort. — (Aiivard.) 



248, Gynandria. — The external organs of the female re- 
semble those of the male. The clitoris is large, with possible 



202 



GYNECOLOGY. 



fusion of the labia majora, not infrequently of the labia minora, 
simulating the scrotum and concealing the vulvar opening. 
This resemblance is still more striking when there is associated 
an ovarian hernia into the labium majus. The internal organs 
may be irregularly developed. The hypertrophy of the clitoris 
does not necessarily change its form, and may arise in women 
who are addicted to masturbation. The labial fusion may 
be so firm as to require incision. 

An example of this class is Madeline Le Fort (Auvard) 
(Fig. 157), who was declared to be a female by Beclardjwhen 




Fig. 158. — Outline of Internal Organs of Madame Le Fort. — (Auvard.) 



she was six years of age. The clitoris was very large; a groove 
upon the under surface led to a depressed urethra in the cleft 
of the vulva. The vagina was replaced by a small conduit, 
from eight to ten centimeters long, bordering upon a well- 
formed uterus (Fig. 158). Menstruation occurred at the eighth 
year, and escaped from an orifice situated at the root of the 
clitoris. Her general appearance was strongly masculine, 
and she was sexually indifferent. 

249. Androgyna. — This class predominates, and its individuals 
are frequently monorchid or cryptorchid males, presenting ex- 



MALFORMATIONS. 



203 



ternal characteristics of the female, such as enlarged breasts. 
The penis may be perfect, but the nondescent of the testicles 
and a median depression in the scrotum resembling the labia 
majora will give a distinctly feminine aspect. Arrested devel- 
opment of the penis, hypospadias, and fissure of the scrotum 
greatly increase the resemblance (Fig. 159). Such persons 
are generally dressed, reared, and educated as girls, and have 
been married without being aware of their true sex. 

The determination of sex is of great importance. It re- 
quires careful consideration of the size, shape, and general 
configuration of the body. The testicle may be small, and 
be retained within the abdominal cavity. The secretion of 
the semen is generally sterile. The breasts resemble the 
feminine, as do also the buttocks and thighs. The larnyx 
is not prominent and the beard is scanty or 
absent. The rectal touch, with the catheter 
in the bladder, may fail to reveal either 
uterus or prostate. The mental condition is 
generally feeble or poorly balanced. When 
careful examination fails to render the sex 
certain, the individual should be classed as 
a male. Independent of increased freedom 
and larger opportunities for acquiring a live- 
lihood, the imperfect male is less likely to 
enter upon the marriage relation. 

250. Atresia of the urethra and vagina has 
been noted, but a fetus with this condition 
is nonviable. 

251. Hypospadias is much more rare in 
the female than in the male. The vestibule 
is absent and the orifice of the urethra is 
not visible to inspection. Generally, the ap- 
parent hypospadias is really a persistence of 
the urogenital sinus. The urethra can be 
wholly absent, and the bladder may present 
a crescentic opening into the vagina. It is often associated 
with prolapse of the bladder-wall, and incontinence is usually 
present. 

252. Epispadias is still more rare. It presents four varieties: 
(i) The corpora spongiosa are separated, and the urinary sinus 
is situated in the posterior surface of the clitoris; (2) added 
to the former condition, there is a partial defect of the anterior 
urethral wall; (3) the anterior wall of the urethra is entirely 
absent, the clitoris is bifid, and the labium minus is attached 
on either side to a portion of the glans clitoris, while the pubic 
symphysis may also be defective ; (4) exstrophy of the bladder. 




159. — Androgy- 
na. — {Pozzi.) ^^. 



204 



GYNECOLOGY. 



in which the anterior wall of the abdomen, with that of the 
bladder, is absent and the posterior vesical wall protrudes. 
The ureters open upon the surface, and the parts are constantly 
soiled with urine. 

The first form of epispadias is very rare, the last most f re- 




Fig. 1 60. — Imperforate Anus. Communication between Rectum and Vagina. 



i 


fr" "'' 




• 


^ 






1 




s _ 


■^n^ 


/ 



Fig. 161. — Congenital Defect of Vagina. Communication with the Rectum. 



quent. While vesical ectopia is prone to result in disease and 
obstruction of the ureters, which lead to hydronephrosis and 
early death, nevertheless histories of patients have been re- 
ported who have reached old age. The occurrence of epi- 



MALFORMATIONS. 



205 



spadias and associated incontinence is not inimical to the oc- 
currence of conception, and cases of pregnancy at full term 
are recorded. 

Treatment. — The urethra may be established by denuding 
and suturing the surfaces, but failure to secure a good result 
is frequent. Ectopia of the bladder is difficult of correction. 




Fig. 162. — Congenital Alj-sence of the Urethra. Communication of Bladder 

with the Vao:ina. 




Fig. 163. — Communication of Rectum and Bladder with the Vagina. 



It is preferable not to attempt an operation during infancy, 
owing to the friability of the tissues and the probability of 
sutures cutting through. Transplantation of the ureters into 
the rectum probably affords the most satisfactory solution 
of the problem. 



206 



GYNECOLOGY. 



253. Duplication of the bladder has been found associated 
with doubHng of the genitaha. 

254. Open Urachus. — PermeabiHty of the urachus and dis- 
charge of urine from the umbiHcus is a result of congenital closure 
of the urethra, but sometimes occurs independently. It is much 
more frequent in boys than in girls. 

255. Irregular Exit of Ureter. — Opening of the ureter into 
the vagina has been described, but these are probably cases 
in which the supposed vagina is really a rudimentary bladder. 
I had an opportunity to examine a young woman in whom the 
bladder was rudimentary and the vagina formed a receptacle in 
which urine accumulated and prevented incontinence becoming 
complete. Baum describes an accessory ureter which opened at 
the side of the urethra. He operated by making an incision 
above the symphysis, cutting through the bladder upon the 




Fig. 164. — Suprapubic Opening of Vagina and Urethra. 



ureter, which he divided, tying the distal end, while the other 
was brought into the bladder. The procedure overcame the 
incontinence. 

256. Abnormal Communications. — Errors in development 
may produce imperforation of one of the canals which per- 
forate the pelvic fascia or result in the union of two or three 
of them. In any case the cause is analogous: i. e., failure to 
accomplish the union between the superficial and deep organs. 
Imperforations of the anus and urethra are vital, calling for 
prompt attention of the surgeon. Imperforation of the vagina 
has been considered. (Section 237.) The communications may 
be: 

I. Rectovaginal. (Fig. 160.) The vagina and urethra are 
normally developed. The anus is imperforate and, therefore, 



TRAUMATISMS. 207 

the fecal material is discharged by a rectovaginal opening through 
the vagina. 

2. Vaginorectal. (Fig. i6i.) The rectum and urethra are 
normally developed, excepting the opening into the former 
from the incomplete vagina. 

3. Vesicovaginal. (Fig. 162.) The rectum and vagina are 
normal in appearance, but the urine escapes through the latter, 
the urethra being absent. 

4. Rectovaginovesical. (Fig. 163.) The rectum and bladder 
both communicate with the vagina. The urethra is generally 
absent. The anus may or may not be perforate. 

5. Suprapubic opening of vagina and urethra. (Fig. 164.) 
This condition is extremelv rare. 



TRAUMATISMS. 

257. Injuries of the genital organs of sufficient gravity to 
produce temporary or permanent structural changes, to in- 
fluence the subsequent health and comfort of the patient, are 
for the most part limited to lesions of the vulva, vagina, and 
cervix. 

The causes productive of such conditions may usually be 
assigned to one of three general classes, viz. : 

1. External violence. 

2. Coition. 

3. Parturition. 

258. External Violence. — The cases of injury from external 
violence are comparatively infrequent. 

They occur in a variety of ways. 

A woman standing upon a chair or step-ladder falls astride 
the back, or upon the post or round of the chair. 

Bovee reports the case-history of a young girl who fell from 
her bicycle upon the lamp bracket and sustained a complete 
laceration of the perineum. Lacerations may be produced 
by sliding down bannisters and striking against the newel 
post, by sliding from a haystack or haymow, falling upon the 
handle or prong of a fork or upon a hay-knife. Howe men- 
tions a young woman who thus slid upon the handle of a fork, 
which entered the vagina and punctured the abdominal cavity 
twenty-two inches, and from which she ultimately recovered. 
Curran cites the case of a patient in w^hom the horn of a goat 
entered the anus and tore through the vagina. Girls have 
been impaled upon barrel staves, fence palings, or the sharp 
stump of a sapling. A chamber or slop jar breaking under 
the patient has been the cause of injury. The fracture of a 



208 GYNECOLOGY. 

glass-ball pessary in the efforts for its removal has produced 
vaginal laceration and even fistula. Royster reports two cases 
of complete laceration of the perineum in young girls, which 
were caused by the finger of the obstetrician while they were 
yet within the body of the mother. The injury may be a free 
incision, a ragged laceration, or a severe contusion. The in- 
cision may be produced by striking upon a blunt object, the 
sharp edge of the rami cutting through the overlying tissues. 
Large vessels may be ruptured without the skin being broken, 
when a severe hemorrhage will occur into the tissues. In 
the former case the hemorrhage will be open; in the latter, 
concealed. 

Treatment. — The injury of vessels and the resulting hemor- 
rhage into the tissues is called pudendal hemorrhage (see Vulvar 
Hematoma). This may demand evacuation, and the resort 
to measures for the control of the bleeding vessels. 

Severe hemorrhage following an injury should demand 
an inspection of the injured part and the resort to measures 
for its control. Where a good-sized vessel is bleeding, the 
wound, if necessary, should be enlarged and the vessel ligated. 
Frequently the hemorrhage can be controlled by the sutures 
which are employed to close the wound. General oozing from 
a ragged opening is often best controlled by gauze pressure. 
The wound must be carefully cleansed and maintained in an 
aseptic condition. 

259. Coition, as is well known, causes a rupture of the mem- 
brane — the hymen — which guards the vaginal opening. Lacera- 
tion of this structure is usually central and posterior. It may, 
however, be bilateral. Occasionally, as has been seen, the 
hymen is so firm as to resist all attempts at coitus, and, there- 
fore, will require incision before the act can be accomplished. 

The entire vaginal canal is more or less dilated by the re- 
petition of the sexual act, as is evidenced by the enlarged and 
roomy canal which distinguishes the nulliparous from the 
virgin vagina. Severe lacerations of the vulva and vagina, the 
result of sexual intercourse, are rare, except when produced 
by rape of young girls. Instances are reported, however, in 
which injuries of gravity have been produced, as the pushing 
off of the hymen, the perforation of the posterior vaginal wall, 
the rupture of the perineum, the formation of rectovaginal 
fistula, and perforation of the posterior vaginal fornix. Such 
injuries are more likely to occur in those who come to the first 
coitus late in life, or in whom there have been premature atrophic 
changes. Skrobanski, however, cites a young peasant, aged 
twenty-two years, in whom the first coitus caused a rupture 
of the perineum, two centimeters in depth, but without enter- 



TRAUMATISMS. 



209 



ing the rectum. R. Abrahams reports the history of a woman, 
twenty-six years old, in whom a recto-perineal fistula was 
produced which permitted the introduction of two fingers. 

Occasionally the first coitus is followed by a hemorrhage 
so active as to endanger the life of the woman. The bleeding 
is best controlled by the introduction of a suture to include 
the spurting vessel. 

Treatment. — Injuries resulting from the sexual act are 
rarely of sufficient importance to demand surgical interference. 




Fig. 165.— Knives for Denudation. 




Fig. 166. — Curved Scissors. 




Fig. 167. — Retractor. 



If severe, the treatment will depend upon the character and 
extent of the injury. An extensive laceration should be sutured. 
The sexual act should be discontinued until the injured parts 
have fully recovered, and it then should be practised with the 
utmost gentleness and care. 

260. Parturition. — Maternity is not without its penalty. 
The great majority of the injuries to which the genital organs 
are subject occur during, or are the result of labor. The in- 

14 



210 



GYNECOLOGY, 



juries are due to faulty anatomic conditions, as distorted pelves, 
rigid, unyielding muscles, inflamed and undilatable cervices, 
abnormal positions of the fetus, disproportion between its size 
and that of the pelvis, violent uterine contractions, long-delayed 
and feeble contractions, the premature or too long postponed 
instrumental or manual interference. 

The long-continued pressure of the fetal head impacted 
in the pelvis is probably even more disastrous than the pre- 
mature delivery by the application of forceps. Indeed, vesico- 



Fig. 1 68. — Blunt Hook. 




Fig. 169. — Needle-holder. 




-Ph 



-Needles. 




Fig. 171. — Needle with Loop for Suture. 



vaginal fistulas, which were of frequent occurrence prior to 
the educated use of the forceps, now rarely come under ob- 
servation. The injuries are of great variety and affect the 
uterus, — ^both body and cervix, — the vagina, the vulvar out- 
let, and particularly the perineum. 

261. Injuries of the body of the uterus may occur in the 
form of lacerations of the anterior or posterior wall, in a vertical 
or transverse direction, and may be slight or sufhciently large 



TRAUMATISMS. 211 

to permit the escape of the fetus and placenta. After an abor- 
tion, the softened uterine wall is occasionally perforated by 
the curet or placental forceps or both, and through these per- 
forations loops of intestine have entered the uterine cavity, 
been drawn through the os, and subjected to serious injury. 
Injuries of this structure are not confined to parturition alone, 
but the walls of the inflamed or flexed nonpuerperal organ are 
frequently perforated by the use of the sound or bougie. In 
removal of fibroid growths, the weakened wall can be ruptured 
and the tumor projected through it, or the fundus uteri can 
become inverted and be incised during the removal of the growth. 

Treatment. — For the proper course of treatment in rupture 
of the uterus, during labor, the student is referred to one of the 
text-books on obstetrics. Perforation of the uterus in the 
effort to evacuate decomposing placenta or membrane follow- 
ing an abortion should demand careful subsequent observation. 
In such cases the danger of perforation is so great that the 
retained fragments should be removed, if possible, by the finger, 
and placental forceps should only be used with the finger as 
a guide. Evidence of perforation as presented by bringing 
a coil of intestine to the os should require careful replacement 
of the knuckle of the intestine and a certain determination 
that it has been pushed entirely through the uterine wound, 
after which the uterus should be packed with iodoform gauze. 

Any appearance of shock, disturbance of temperature, or 
continued and severe irritation of the stomach should be recog- 
nized as an urgent indication for abdominal section. Perfora- 
tion of the uterine wall by sound or bougie, unless associated 
with infection, has but little significance. Care should be 
exercised, however, not to irrigate with irritating fluids, and 
drainage of the uterus should be secured by gauze. The lacera- 
tion of the uterus during removal of fibroid growths should be 
considered requisite for immediate suturing of the wound 
through an abdominal section. 

262. Injuries of the cervix uteri are described under the 
term laceration. Laceration of the cervix is the most frequent 
lesion of labor. It is exceedingly rare for a woman to undergo 
her first parturition without the cervix being more or less fissured. 
The tear may vary from a slight fissure, which completely 
disappears during convalescence, to an extensive laceration, 
extending to or into the vaginal fornices. 

Lacerations of the cervix are unilateral, bilateral, stellate, 
and through the anterior or posterior lip. The bilateral is 
the most frequent. The unilateral is more frequently found 
upon the left side, owing to the greater preponderance of the 
left occipito-anterior position. Lacerations can occur into the 



212 GYNECOLOGY. 

cellular tissue laterally, or into the bladder in front, and thus 
cause a vesico-uterine fistula. (See Section 285.) The cicatri- 
zation of a lateral tear may produce a band or bridle which tilts 
the fundus uteri to the opposite side. 

263. Symptoms of laceration of the cervix present no special 
or specific indications of its existence. The symptoms are 
those produced by the conflicting conditions. The lesion 
causes subinvolution and a consequent increased weight. A 
bearing-down sensation, discomfort in standing or walking, 
and pain in the sacrum and iliac regions are common. The 
lower level maintained by the organ and the traction of the 
vaginal wall upon its lips leads to separation of the latter, 
e version of the cervical mucous membrane, thickening of the 
tissue from its exposure, and fixation of the everted lips. Ir- 
regular or excessive menstruation, or metrorrhagia, is not 





^^^«l^igS9^«^' 



Fig. 172. — -Slight Fissure of Cervix. Fig. 173. — Extensive Laceration of 

Cervix. — (Munde.) 



infrequent. Bleeding is excited by locomotion, coition, or 
sexual excitement. The endometritis causes a profuse leu- 
korrhea, which constitutes a double drain. The cicatricial 
bands and the everted lips not only permit a depression of the 
uterus in the pelvis, but produce either lateral version or retro- 
version, according to the unilateral or bilateral character of 
the lesion. With cicatrization of the lacerated surfaces, not 
infrequently the scar tissue in the angles of laceration causes 
pressure upon the nerves, producing profound neurotic or 
reflex phenomena. Not infrequently the presence of neu- 
rasthenia may be created by pressure of the cicatricial tissue 
upon the nerve filaments. Pressure with the finger against 
such indurated tissue aggravates the reflex phenomena. 

264. Diagnosis. — A laceration of the cervix is readily recog- 
nized by the finger, but its apparent presence must not be 



TRAUMATISMS. 



213 



accepted as proof positive of previous pregnancy, for congenital 
fissure has been recognized, which permits as marked eversion 
of the Hps as is produced by a deep bilateral tear. The finger 
will also disclose the condition of the lesion, whether it is cica- 





Fig. 174. — Bilateral Laceration of 
Cervix. — (Munde.) 



Fig. 



5. — Slight Stellate Laceration 
of Cervix." — -(Munde.) 



trized, the eversion of its lips, the presence of erosion, which is 
disclosed by its soft, velvety feel, or the existence of eversion 
of the cervical mucous membrane. Inflammation and obstruc- 
tion of the glands of Xaboth will be disclosed by small, shot- 
like masses studding the cervix. Passing the finger upward, 





Fig. 176. — Extensive Stellate Lacera- 
tion of Cervix. — (Alunde.) 



177. — Laceration of Cervix with 
Hypertrophy and Eversion of 
Cervical IMucous IMembrane. — 
(Munde.) 



the lips will be found spread out, like the top of a celery stalk, 
but hard, dense, and fixed. 

The bivalve speculum, in drawing upon the anterior vaginal 
wall, aggravates the eversion. The tubular speculum fiattens 
the surface, removes all trace of the fissure, and leads to the con- 



214 GYNECOLOGY. 

dition being mistaken for granular erosion. The Sims or some 
retraction speculum affords the best exposure. Seizing each lip 
with a tenaculum and drawing them together discloses the ex- 
tent of the tear (Fig. 179). The surface of the tear is covered 
with exuberant granulations, which bleed upon the slightest 
touch (Fig. 177), and the profuse discharge renders the differ- 
entiation from epithelioma sometimes exceedingly difficult. 
The diagnosis may be established by the results of treatment. 

265. Treatment. — Immediate examination after labor to as- 
certain the possibility of laceration is undesirable. While the 
cervix is thin, soft, and relaxed, the lesion can still be recognized. 
The majority of. small lacerations close spontaneously under the 
employment of ordinary antiseptic precautions. The existence 
of severe arterial hemorrhage should require an examination to 
ascertain its source, and when found, is best controlled by sutur- 
ing the lacerated surfaces. Not every laceration demands an 
operation, and if not done within the first ten days, three months 
should pass before is it repaired. Small fissures which are in- 
clined to close or have cicatrized, do not require an operation. 
When the lesion is complicated with endometritis, the latter 
should be treated. Operation in slight cases is to be condemned, 
as it obstructs drainage and may cause the extension of disease 
to the tubes and pelvic peritoneum. Repair is indicated in 
deep laceration, in e version with hypertrophy and cystic degen- 
eration of the mucous membrane, in cicatricial formation at the 
angles of the fissure producing reflex phenomena, and in sub- 
involution and endometritis. In addition to slight lacerations, 
and those which have cicatrized, surgical interference confined to 
this lesion is contraindicated in tubal or peri-uterine disease. 

266. The presence of endometritis, of marked e version and 
hypertrophy of the mucous membrane, requires treatment prior 
to the operation for laceration. The patient's diet should be 
regulated, constipation corrected, and appropriate measures in- 
instituted to relieve the accompanying anemia ; a vaginal douche 
of hot water, containing an ounce of rock salt to the quart, 
should be frequently employed. The cervix should be scarified 
or punctured, thus securing depletion. All obstructed Nabothian 
glands should be punctured and the gland cavity painted with 
Churchill's tincture of iodin, a combination of tincture of iodin 
and creasote (2:1), iodin crystals dissolved in 95 per cent, 
carbolic acid solution, silver nitrate (5j to foj), zinc chlorid 
(5j to fSj), or pyroligneous acid. The superfluous material 
should be sponged away and a tampon of gauze and cotton 
applied beneath the uterus. By raising the organ to a higher 
level the sensation of weight or heaviness is removed and the 
circulation is improved. 



TRAUMATISMS. 215 

The tampon may consist of plain sterilized gauze and cotton, 
medicated gauze (iodoform, carbolic or boric acid, or thymolized) . 
Sublimated gauze should not be used, because it causes pruritus. 
The tampons may be medicated with preparations of glycerin, 

R . Pulv. alum. , § j 

Acid, carbolic. .^ iv 

Glycerin., ,^ xij 

a fifty per cent, solution of boroglycerid, or a ten per cent, solu- 
tion of ichthyol. In place of the glycerin the tampon can be 
medicated with an ointment, such as twenty-five per cent, 
of ichthyol in lanolin. The local treatment, followed by a 
tampon, should be applied twice a week, and the latter removed 
at the end of forty-eight hours, to be followed by a vaginal 
douche of half a gallon of hot salt water (temperature from 
iio° to 120° F.) twice daily. The douches are preferably given 
with a fountain (gravity) syringe, while the patient is in a 
recumbent position on a bed-pan ; although in those cases 
in which the cervix and the neighboring tissues contain a large 



Fig. 178. — Blunt and Sharp Curets. 

amount of inflammatory exudate the bulb (Davidson) syringe^ 
by force of its current, exercises a salutary influence, by pro- 
moting absorption. A profuse discharge of glairy mucus from 
the surface should be removed with a blunt curet. The curet 
presses the mucus-collections from the cervical glands and 
permits the application to come directly in contact with the 
diseased surface. The medicament may be applied by means 
of a cotton-wrapped probe, or be carried into the canal with a 
pipet. (Fig. 82.) Intracervical applications should not be 
made, however, unless the cervical canal is quite patulous, so 
that the fluid or increased serous discharge can readily escape. 
If the canal is obstructed by hypertrophied and everted mucous 
membrane, gauze packing (Section 82) or the use of a laminaria 
tent (Section 77) will render the application more effective and 
safe. Irregular bleeding or profuse leukorrhea should indicate 
the use of the sharp curet (Section 83), after dilatation (Section 
79). The uterus should be irrigated during or following curet- 
ment with a disinfectant solution, bichlorid, i : 3000 ; formalin, 
1 : 1000, a hot soda solution 4 drams to 2 pints, or preferably 
with normal salt solution, and swabbed with a saturated solution 



216 



GYNECOLOGY, 



of iodoform in ether. If for any reason there is much bleeding 
following the procedure, the uterine canal should be packed 
with iodoform gauze. 

267. Trachelorrhaphy (that is, neck-sewing), or hystero- 
trachelorrhaphy (that is, womb-neck sewing), is the operation 
devised by Emmet for the relief of laceration of the cervix. 
Patient, prepared (Section 119) and anesthetized (Section 127), 
is placed upon a table in the lithotomy position, with a perineal 
pad beneath her buttocks to carry the irrigating fluid into a 
slop- jar at the end of the table. Each leg is held by an assistant 
or secured by a leg-holder. The following sterile instruments 
(Section iii) have been placed in a tray upon a table at the 
operator's right: a scalpel or bistoury; curved scissors; long, 

rat-toothed dissecting for- 
ceps; two double tenacula; 
a retraction speculum (Ede- 
bohls') ; six pressure forceps; 
a needle-holder; four strong 
needles, curved and bay- 
onet-pointed, each threaded 
with a loop of silk to serve 
as a suture carrier. A smaller 
tray will contain the suture 
material. My preference for 
sutures is chromic catgut, 
which has the advantage 
that it does not have to be 
removed (Section 113). The 
nurse at the operator's left 
should have charge of the 
sponges. There should pref- 
erably be "Sterilized gauze, though absorbent cotton wet with sub- 
limate solution, I : 2000, can be employed. A fountain syringe, 
filled with hot normal salt solution or some disinfecting fluid, 
should be suspended, so that the field of operation can be sub- 
jected to constant irrigation. The final preparation of the patient 
(Section 119) completed, the cervix is exposed with a speculum, 
and each lip so seized with a double tenaculum as to turn in 
the everted edges when the lips are apposed. (Fig. 179.) The 
assistant upon the operator's left holds the tenaculum in the 
anterior lip and controls the irrigation tube; the one upon the 
right attends to the necessary sponging. The posterior lip is 
held by the weight of the tenaculum. With the knife the 
operator cuts through the cicatricial angle, and with scalpel 
and forceps denudes a corresponding surface upon each lip, 
in a bilateral laceration, first upon the left, then upon the right. 




Fig. 179. — Edges of Laceration Turned 
by Tenaculum Hooked into Each Lip. 



TRAUMATISMS 



217 



The knife is preferred to the scissors, as the denudation can be 
made more evenly and with less bruising of tissue. The de- 
nudation is, of course, limited to one side in a unilateral tear. 
A strip of undenuded mucous membrane, one centimeter wide, 
should be left in each lip for the future cervical canal, and the 




T 









/ 



Fig. i8o.- 



■Denudation of Lacerated 
Cervix. 



Fig. 



i8i. — Surfaces Denuded Ready 
for Union. 



(Fig. 1 80) precaution should be exercised not to encroach upon 
the vaginal surface of the cervix in the removal of the tissue. 
In deep lacerations the circular artery may be opened in the 
denudation. It should be seized with pressure forceps, and 
the first suture should be so introduced as to control it. 





Fig. 



-Sutures Introduced. 



Fig. 183. — Sutures Tied. 



The sutures are placed by introducing the needle about 
three millimeters from the vaginal edge of the wound, bring- 
ing it out at its cervical margin, introducing it at a similar 
point in the other lip, and bringing it out in the vagina. Or- 
dinarily, three sutures will be sufficient upon each side. Oc- 



218 



GYNECOLOGY. 



casionally, the laceration will be so deep that the angle suture 
can not be properly placed by passing the needle as we have 
just described. It is then preferably introduced from within 
outward, which can be done by carrying the ends of the suture, 
by means of the carrier, through first the posterior and then 
the anterior lip, or with two needles threaded with carriers, 





Fig. 184. — Double Flap Amputation 
of the Cervix. — {Auvard.) 



Fig. 185.— Sutures Introduced. 
(Auvard.) 



each passed from within outward, the one anterior and the 
other posterior. One carrier is passed through the loop of 
the other and drawn out. The loop thus carried through serves 
to carry the suture. The sutures are tied, superficial sutures 
are introduced, if needed, and the vagina is thoroughly irrigated. 
If bleeding should continue, a suture should be introduced 

well above the denudation to control 
the bleeding vessel. Avoidance of sub- 
sequent hemorrhage is particularly de- 
sirable, if a plastic operation is also 
to be performed upon the vaginal 
outlet. 

268. Amputation of the cervix is to 
be preferred when the cervix is much 
elongated and hypertrophied, when the 
mucous membrane has become exten- 
sively hypertrophied and everted, and 
when cellular proliferation justifies the 
suspicion of incipient malignant degen- 
eration, although when the latter con- 
dition is established complete hysterectomy would be the better 
course to pursue. 

The amputation can be made by the double or single flap 
method for each lip. The instruments and preparations are 
similar to those given in the previous section. (Section 267.) 




Fig. 186. — Wound Closed. 



TRAUMATISMS. 



219 



Double Flap Operation. — The lips of the cervix are seized 
and separated by double tenacula; an incision is made in each 
angle to the point at which it is desired to make the amputation. 
A wedge-shaped piece is removed from each lip, forming cer- 
vical and vaginal flaps. Two sutures are then introduced in 
each lip, uniting the cervical and vaginal mucous membranes. 
On each side a suture is passed in through the anterior vaginal 
and cervical flaps, out through the similar posterior flaps, and 
external to this such sutures as are inserted are necessary to 
bring in apposition the raw surfaces. The sutures are tied 
and superficial sutures in- 
troduced, if necessary, to 
nicely adjust the edges of 
the wound. The more ac- 
curate the adjustment, the 
less will be the subsequent 
contraction. 

Single Flap Method. — 
Schroder's operation con- 
sists in making the denu- 
dation at the expense of 
the internal or cervical 
portion of each lip. This 
operation is preferable 
when the cervical mucous 
membrane is so diseased 
and hypertrophied as to 
render its retention for 
the formation of a flap 
undesirable. In this, as in 
the former operation, a 
lateral incision is made 
and the lips are everted. 
Instead of a cervical flap a 
transverse incision is made 
into the lip from within 

outward, at the level of the lateral incision, cutting half through 
the lip; then a vertical incision to the junction of the cervical 
and vaginal mucous membranes. Two sutures unite the end of 
each flap to the corresponding cervical mucous membrane, and 
the remaining raw surfaces are adjusted by lateral sutures. 

269. After-treatment.— The after-care does not differ in 
the various operations upon the cervix. In the use of the 
chromic catgut suture no provision is made for its removal, 
but it is important to preserve it from becoming infected. Un- 
less the vaginal outlet is to be the seat of an operation, the 



1 


j 


i 


h^ 


^k^^j 


nS^ 


i^^ 




^' 


^w 


■•-«£!■■ 


^^Hr 


,^^^^ilH 


HI^^Bpi^^ ^ 



Fio-. 1 87. 



-Schroder's Single Flap Opera- 
tion. 



220 



GYNECOLOGY. 



vagina should be loosely packed with gauze , which should be 
removed in two or three days. The patient is kept in bed 
for two weeks, and then gradually permitted to resume her 
ordinary duties. Any pain should be relieved by the application 
of an ice-bag to the abdomen. The patient should void her 
urine, and the catheter should be used only when it is impos- 
sible for her to empty her bladder while in the recumbent pos- 
ture. Secure an evacuation of the bowels at least each alter- 
nate day. Avoid vaginal douches for the first forty-eight 
hours, affording the plasma opportunity to glue the apposing' 
surfaces; then use a douche of hot sublimate solution (i : 3000), 
formalin (i : 1500), or a i per cent, saline solution twice daily. 
Direct the patient to avoid worry or much exercise during 

the next menstrual period, 
and not to resume the sexual 
relation for one month. 

270. Lacerations of the 
Vagina. — Small tears of the 
anterior, posterior, or lateral 
wall of the vagina are not 
infrequent, and result in ci- 
catrices which produce more 
or less disturbance of the 
pelvic functions. Separation 
of the muscular wall can 
occur without lesion of the 
mucous membrane. Not in- 
frequently the entire vagina 
is crowded away from its 
muscular attachments, so 
that it subsequently appears as a relaxed sac, falls into folds 
which drag upon the cervix, displace the uterus, or, when it is 
fixed, produce hypertrophic elongation of the cervix. The most 
frequent lesions are at the vaginal outlet, and involve that por- 
tion of the pelvic floor known as the perineum. These lesions 
of the vagina are so intimately associated with, and dependent 
upon, the condition of the perineum that their treatment will 
be discussed with the lesions of the latter, under the head of in- 
juries of the pelvic floor. Lesions of the genital canal, especially 
of the cervix and vagina, may be induced by long-continued 
pressure of the head of the child during a protracted labor. The 
loss of tissue vitality will necessarily be dependent upon the 
severity and duration of the pressure. 

It may involve only the superficial structures, as an erosion 
or superficial sloughing, when the tissues may be regenerated 
or, if more extensive, there results contraction and stenosis 




Fig. 188.- 



-Schroder's Operation Com- 
pleted. 



TRAUMATISMS. 221 

or partial or complete obliteration of the canal, known as ac- 
quired atresia. Acquired atresia most frequently follows in- 
juries occurring during parturition, but it can be produced by 
irritating injections and severe inflammations. Atresia vaginae 
often occurs as a sequel of senile vaginitis. In one patient I 
found the entire vagina obliterated. The symptoms of such 
a condition are necessarily dependent upon the time of life 
at which it occurs. AVhen it follows senile vaginitis, it often 
produces no symptoms outside those of marital inconvenience. 
During the menstrual life of the woman, the symptoms are 
similar to those of the congenital variety. The patient suffers 
from menstrual molimina and a pelvic tumor follows. When 
the vagina is the seat of atresia, the condition is easily recog- 
nized, as is the uterine accumulation, if the obliteration occurs 
at the external os. When the obliteration occurs at the internal 
OS, however, and the cervix is apparently normal, the diagnosis 
is more difficult, and the disorder may be confounded with 
fibroma uteri, malignant disease, or pregnancy. The careful 
analysis of the patient's history, associated with the examination, 
should afford a reasonable suspicion as to its character. 

271. Fistulae. — ^Deep sloughs involving a portion of the 
genital tract occasionally lead to perforation of one of the ad- 
joining viscera, and we then have a fistula. The anterior wall 
is the most frequently affected, and, consequently, results in a 
urinary fistula, which may involve urethra, bladder, or ureter, 
and be associated with extensive destruction of vagina and 
cervix. Fistulae are divided into urinary and fecal. 

The genito-urinary fistulae are: 

1. Urethrovaginal. 

2. Vesicovaginal. 

3. Vesico-uterine. ) (Fig. 189.) 

4. Uretero vaginal. \ 

5. Utero-ureterine. / 
The fecal fistulae are: 

1. Anovulvar. ^ 

2. Rectovaginal. - (Fig. 189.) 

3. Entero vaginal, j 

272. Etiology. — Fistula are most frequently caused by 
the accidents of labor. These lesions are of less frequent oc- 
currence than formerly, the result of improved methods of 
delivery, by which the progress of the fetus is expedited and 
the maternal parts are saved from long-protracted pressure. 
Fistulae are rarely the result of tearing, but generally follow 
a slough. Awkward use of instruments can result in perfora- 
tion of the bladder or the rectum, but such lesions present a 
marked tendency toward spontaneous recovery. 



222 



GYNECOLOGY. 




*^, 



Other causes of fistulas are cancer involving the anterior 
or posterior vaginal walls, tuberculous disease, surgical opera- 
tions, ulceration from the presence of a vesical calculus, and 
abscesses or phlegmons. 

273. Symptoms. — The presence of a urinary fistula is recog- 
nized by incontinence of urine and by the appearance of urine 
in the vagina. A fecal fistula will permit the discharge of 
liquid feces and gas. A few days subsequent to her confine- 
ment the patient complains of being unable to retain her urine, 
or possibly it may come with a gush, following the partial or 
complete separation of a large slough. The parts are afterward 
continually bathed with urine, the skin becomes reddened 
and irritated, and the salts of the urine are deposited, increas- 
ing the irritation. The 



clothing of the patient 
is saturated with de- 
composing urine, caus- 
ing a disgusting odor. 
Partial continence 
may be present when 
the opening is small, 
when it is situated 
high in the vagina, or 
when it affects but 
one ureter. The in- 
fluence of a fecal fis- 
tula depends upon its 
size and situation. A 
small opening may 
permit the escape of 
the contents of the 
intestine only when 
they are liquid. The 
odor of the vaginal secretion is exceedingly offensive, so that 
the patient suft'ers an enforced retirement. 

274. Diagnosis. — Incontinence should at once awaken a 
suspicion of a fistula. Large fistulas are readily recognized by 
vaginal palpation. Small fistulas, associated with cicatricial 
contraction of the vagina, are often difficult to expose. The 
entire surface of the vagina should be exposed with retractors 
or with a Sims speculum lender a good light. If the opening 
is small, it will be revealed by injecting the bladder or rectum 
with milk or other colored liquid, when the opening will be 
observed as the liquid escapes into the vagina. 

This procedure affords a means for differential diagnosis 
between ureteric and enteric fistulas. The escape of clear 





Scheme Showing: Various Fistula. 



TRAUMATISMS. 



223 



urine into the vagina when the bladder is filled with a colored 
liquid demonstrates the ureter as the origin of the fistula. The 
introduction of a ureteral catheter into the sinus and of a sound 
into the bladder permits the recognition of the intervening 
septum. If the opening is small and not visible, dry the sur- 
face and apply blotting-paper while the bladder is being filled. 
The paper will be moistened at the site of the fistula (Pozzi). 
The same object can be attained by packing the vagina with 
sterile gauze and injecting 
the bladder with colored 
fluid. The staining of the 
gauze will indicate the 
situation of the opening. 
In enteric fistula the va- 
gina is constantly bathed 
with liquid feces, and the 
appearance of the dis- 
charge is not affected by 
rectal enemata. There is 
an offensive vaginitis and 
the patient suffers from 
inanition. In supposed 
uretero-uterine fistula the 
position of the ureters 
should be examined by 
Sanger's method. (See Sec- 
tion 95.) It has been sug- 
gested that the patient 
urinate, then sit two hours 
upon a vessel, when a cath- 
eter is used; and if the 
quantity thus secured is 
equal to that in the vessel, 
there is a ureteric fistula. 
The collection has been ob- 
tained from separate kid- 
neys. 

The most ready method 
of recognizing the ureteric 
fistula^ is by injecting the bladder with colored fluid. The con- 
tinuation of uncolored fluid in the vagina demonstrates that we 
are not dealing with a vesical opening. 

No^ operation should be attempted for rectal fistula without 
exclusion of rectal stricture. 

275. Prognosis. — The curability of a fistula depends upon its 
cause, situation, size, and duration. Those produced by cancer 




Fig. 190. — Large A'esicovaginal Fistula with 
Prolapse of the Anterior Vesical Wall 
through the Opening. 



224 



GYNECOLOGY. 



are a part of the progress of the disease, and are incurable unless 
the disease can be removed. Spontaneous recovery of punc- 
tured or incised fistula is prone to occur under proper cleanli- 
ness, but an old sinus with hard, cicatricial edges requires sur- 
gical interference. An opening in the base of the bladder is 
more readily relieved than one in the upper part of the vagina 

or one in the urethra. 
Vesico-uterine fistulce are 
particularly difficult, and 
the uretero -vaginal and 
uretero-uterine fistula are 
most trying. 

276. Treatment. — The 
methods of treating vagi- 
nal fistulae as now recog- 
nized may be considered 
as: 

1. Cauterization. 

2. Denudation and su- 
ture of the edges of the 
fistula. 

3. Flap-splitting and 
suture. 

4. Flap-formation and 
sutures. 

277. Cauterization is ap- 
plicable only to fistula of 
small size and where but 
little cicatricial tissue ex- 
ists. The thermocautery 
is the preferable means, 
although caustic potash, 
chlorid of zinc, or one of 
the stronger acids can be 
employed. 

278. Preliminary treat- 
ment is important, what- 
ever the method of operative procedure. The urine should be 
rendered non-irritating by the administration of benzoin salts. 

\i . Ammon. benzoat. , 3 jij 

Tr. hyoscyami, f .^iss 

Ext. buchu ad f,$ij. M. 

SiG. — f 3 j in water three or four times daily. 

This prescription should be accompanied by the ingestion of 
large quantities of water. Hot or soothing vaginal douches 
should be freely employed, as a solution of sodium hyposulphite 




Fig. 191. — Denudation of the Edges of the 
Fistula. 



TRAUMATISMS. 



225 



(oiv, aq. Oj) or weak solutions of the lead salts. If there is an 
incrustation of the lime salts about the orifice and over the 
vagina, employ a solution of dilute nitric acid (gtt. j, mucilage 
water fSj). Cicatricial bands should be incised and stretched; 
the vaginal walls should be incised, to diminish traction upon 
the edges of the fistula when sutured. The cicatrization may be 
overcome by having the incisions heal while a Gariel pessary or 
a colpeurynter is worn. Bozeman employed vaginal obturators 
of plated copper, which, 
when worn, distended the 
vagina and gave more 
room for operation. The 
intestinal canal should be 
thoroughly evacuated. 

279. Vesicovaginal Fis- 
tula. — Injuries of the vesi- 
covaginal septum are the 
most frequent undoubtedly 
because the tissues are 
more likely to be com- 
pressed between the ad- 
vancing head and the pubic 
symphysis. The operation 
of vivifying and suturing 
the edges was revived, per- 
fected, and rendered suc- 
cessful by Sims. i\fter 
thorough cleansing and 
disinfection of the vagina 
and the bladder, the pa- 
tient is placed either in 
the semi-prone position, or 
upon her back with her 
limbs well flexed. The 
perineum is retracted and 
the edges of the opening 
are rendered tense by suit- 
ably applied double tena- 

cula, which are held by assistants. The denudation is per- 
formed w4th knife or scissors, preferably the latter, as the tissues 
bleed less. The denudation is accomplished at the expense of 
the vaginal surface, exercising care to avoid injury to the vesical 
mucous membrane. The mucous membrane is seized with for- 
ceps at one side and the denudation is performed with the at- 
tempt to complete the circuit with the one strip. Having 
secured an equal denudation upon all sides, about one centi- 

15 






Fig. 192. — Sutures Introduced. 



226 



GYNECOLOGY. 



meter in width, the sutures are introduced. They are inserted 
about one centimeter apart, introducing and bringing them out 
about five mihimeters from the edges of the denudation without 
permitting any suture to penetrate the vesical mucous mem- 
brane. The sutures may be introduced anteroposterior, trans- 
verse, X or Y shaped, according to the opening, that direction 
being chosen which will produce the least traction upon the tis- 
sues. The sutures may be silk, catgut, silkworm-gut, or silver 

wire, preferably the latter 
two. After the sutures 
are all in place the bladder 
should be irrigated in order 
to remove all clots, and 
the sutures should be tied, 
twisted, or secured with 
perforated shot, exercising 
care not to draw them 
tight enough to strangu- 
late the inclosed tissues. 
After securing the sutures 
it is well to inject the blad- 
der to make sure that no 
small opening remains. In 
large fistulse care must be 
taken not to injure or con- 
strict the orifice of a ure- 
ter. These canals may open 
upon the surface of the 
fistula, when the vesical 
surface of the ureter should 
be split several days before 
the operation and the sur- 
faces be kept open by the 
frequent use of a probe. 

280. Flap-splitting. — 
The loss of structure by 
denudation in large fistulae 
is not infrequently a serious 
sacrifice of tissue, and has led to the practice of securing fresh 
surfaces by splitting the edges of the fistula. The vesical and 
vaginal surfaces are divided through the cicatrized margin to any 
required depth, according to the size of the fistula. When the 
opening is small, it can be closed by a purse-string suture. The 
suture of silkworm-gut or silver wire is passed through the vagi- 
nal flap within the vesicovaginal septum and brought out in the 
vagina directly opposite its point of entrance, reintroduced near 



V- 




. 4f 




k 


p 

r 


^' 


J 




/ 



Fig. 193. — Wound Closed. 



TRAUMATISMS. 



227 



its exit and made to traverse the remaining side of the opening, 
and brought out near the original entrance. This suture, tied, 
turns the vaginal flap outward and the vesical inward. When 
the size of the opening renders it desirable to close it upon a line, 
the vesical flaps are closed with animal sutures, preferably of cat- 
gut. The vaginal flaps may be closed with silk or silkworm-gut. 
Walcher advocates flrst cutting away the cicatricial tissue, 
then separating the vaginal 



closing 
vaginal 



and vesical surfaces. This 
procedure secures greater 
mobility of the internal 
flaps, which are closed with 
catgut by the Lauenstein 
stitch. The needle is in- 
troduced on the raw sur- 
face and brought out on 
the line of demarcation, 
midway between the raw 
surface and the vesical mu- 
cous membrane, and the 
reverse in the opposing 
vesical flap. After these 
sutures are tied, 
the bladder, the 
flaps are sutured. E. R. 
Corson (Savannah, Ga. ) 
expedites the formation of 
the flaps and the introduc- 
tion of sutures by the use 
of a portion of an india- 
rubber ball. A strong silk 
cord is passed through the 
shank of a shoe button 
which has been made to 
pierce the center of a por- 
tion of a rubber ball; this, 
folded, is carried by for- 
ceps through the fistulous 

opening. Traction upon the string draws down the opening, ex- 
posing its edges. The ease with which the vaginal and vesical 
portions of the septum can be separated renders flap-splitting a 
very ready method for closing large fistulae. This separation can 
be done with impunity, because the circulation of the two surfaces 
is not interdependent. The incision through the vaginal portion 
is preferabty made upon a vertical line. Beginning at one side 
of the fistula, one blade of a suitably curved scissors is inserted 




I 



#•• 



■■\ 



Fig. 



194. — Method of Suturing to Decrease 
the Tension upon the Sutures. 



228 



GYNECOLOGY. 



between the two layers as exposed by the vertical incision (Fig. 
198) and carried completely around the fistulous opening, and 
the walls are separated by blunt dissection. The separation 
may extend to and even through the peritoneum, where neces- 
sary, to secure additional tissue to close the opening. In closing 
a large fistula, the sutures in the vesical wall are preferably 
introduced upon a transverse line, and as they are buried, they 




'i'i'i|li||!i\ir/ 



Fisf. 



195. — Showing Continuation of 
Suturing to Close Fistula with 
Incisions to Decrease Tension 
with Suture Introduced on Left 
Side to Close the Secondary 
Opening. 



Fig. 



-Wound Closed. 



should, therefore, be of chromic catgut. The edges of the 
fistula should be inverted into the bladder. Each extremity 
should be secured by a suture, the end of which, left long and 
used as a tractor, permits the intervening portion to be rapidly 
closed w4th a continuous suture. These sutures should not 
pierce the epithelial surface of the vesical mucous membrane. 



TRAUMATISMS, 



229 




Fig. 197. — Fistula Preparatory to Split- 
ting into Vesical and Vaginal Flaps. 



The closure of the vesical wall should be followed by distention 

of the bladder with a warm 

saline solution to make sure 

that it is tight. The vaginal 

wall should then be closed by 

a vertical line of suturing, 

which may be continuous or 

interrupted, as the operator 

prefers. In introducing these 

sutures the bladder surface 

should be included, to prevent 

the accumulation of serum or 

blood between the surfaces. 

The fact that the vagina has been so destroyed that it will 

not afford material to cover the vesical wall need not deter the 

operator from employing 
this method, as flaps can 
be taken from the labia or 
from the inner side of the 
thighs to complete the va- 
ginal wall. 

M. C. McGannon, of 
Nashville, very ingenious- 
ly closed a fistula in a 
woman who had a lacera- 
tion of the rectovaginal 
septum half-way to the 
cervix, and the anterior 
vaginal wall and base of 
the bladder were gone. 
He dissected the bladder 
away from the uterus and 
pushed the peritoneum off 
until he could bring the 
flap down to the lower 
segment, and closed it 
with fine catgut. After 
closing the bladder, the 
surface was covered as 
much as was possible with 
the remaining portion of 
the vagina. A large sur- 
face was left uncovered 
for cicatrization. The left 
ureter had been included 

in the bladder, but the orifice of the right was situated so high 




Fig. 198. — Demonstration of Flap-splitting. 



230 



GYNECOLOGY. 



in the vagina that it was inaccessible, but was subsequently con- 
ducted to the bladder by an artificially constructed conduit. A 
year later her condition was good, with perfect control of the 
urine. 

In extensive fistula Trendelenburg advocates making a trans- 
verse incision ten centimeters long through the abdominal 




Fig, 199. — Suture Introduced into 
Vesical Flap. 



Fig. 200. — Suture Tied in Vesical 
Flap Introduced in Vagina. 



walls, and a transverse incision through the bladder, just below 
the peritoneal junction. The upper edge of the vesical wound 
is temporarily stitched to the corresponding abdominal, and the 
lower edges of the bladder are held open with sutures. The 
edges of the fistula are trimmed and the sutures so introduced 
that their ends can be brought out and tied from the vagina. 
The anterior vesical wound is closed around a drainage-tube, 
gauze is placed in the prevesical space, and both are brought 

through an opening in the 
abdominal wound, the re- 
maining portion of which is 
closed with sutures. 

Bardenheuer formed a 
flap by transplantation. He 
performed suprapubic cys- 
totomy, and through the 
abdominal wound dissected 
the bladder away from the 
peritoneum as low as the 
fistula, separated the adhe- 
sions and cicatricial tissue, denuded the edges of the fistula 
and sutured them from the vagina, while the edges of the 
fistula were pressed together by the finger passed into the blad- 
der through the suprapubic wound. The abdominal wound is 
plugged with gauze and left open. By utilizing a vesical flap, 
the operation can be performed through the vagina, as described 
above. 




Fig. 201. — Wound Closed. 



TRAUMATISMS. 



231 



281. Flap formation is a procedure practised by Ferguson, 
of Chicago. Ferguson, and E. Stanmore Bishop, of Manchester, 
England, made an incision with a scalpel through the vaginal 
mucous membrane three to six millimeters from the margin 
of the fistula (Fig. 203). This incision completely encircled 
the opening and extended to, but without injuring, the vesical 
wall. The wound was kept free from blood by a stream of 
sterilized water. This procedure formed a circumferential flap. 




Fig. 202.— Sutures Introdticed to Close Vesical Surface, as Suggested by 

Walcher. 



hinged by the A'esical mucous membrane, which, turned into 
the bladder, formed a roof for the raw surface and was held 
in that position by a continuous fine chromic catgut suture 
so inserted that it did not pierce the mucous wall of the organ 
(Fig. 204). The narrow strip of vaginal tissue, which from 
its density retained the stitches well, became a part of the 
bladder- wall. The fistulous opening was thus closed and made 



232 



GYNECOLOGY. 



water-tight. The operation was completed by suturing the 
vaginal walls with silkworm-gut or silver wire. (Fig. 182.) 
Bishop ingeniously inserts four sutures into the edges of the 
flap as constructed by Ferguson, and with a pair of forceps 
passed through the urethra drags these sutures, previously 
knotted, out through that canal. The funnel thus formed is 
closed with a suture from the vagina and the vaginal walls are 
sutured over it. The advantages justly claimed for this plan 



,.#■ 



Fig. 203. — Flap-formation as Suggested by Ferguson. 



are: first, there is no loss of tissue; second, a broad surface is 
secured for apposition; third, there is a projection into the 
bladder at the site of the opening which decreases the danger 
of leakage and infection; fourth, in case the ureter opens into 
the fistula, it affords an opportunity to turn it into the bladder; 
fifth, it decreases the danger of primary and secondary hemor- 
xhages; sixth, in large openings it affords the best opportunity 



TRAUMATISMS. 



233 



to secure relaxation by incision or sliding flaps; seventh, it is 
applicable to fistula of the bladder, urethra, or rectum. 

282. After-treatment. — The vagina, thoroughly cleansed, 
should be lightly packed with iodoform gauze, which should 
remain for two or three days. Continuous drainage should be 
secured by the introduction of a self-retaining catheter into 
the bladder. This should be removed daily, for the purpose 
of cleansing. At the end of eight days it should be removed 




Fig. 204. — Flap Turned in and \'esical Opening Closed. 



permanently; but the patient should be catheterized four times 
daily for the next week. The vagina should be irrigated with 
an antiseptic solution twice daily after the third day, and this 
should be continued for the greater part of three weeks. The 
sutures should be removed on the fifteenth day. 

283. Closure of the Vagina. — Colpocleisis. — Episiostenosis. — 
Large fistulae in which the base of the bladder is destroyed 



234 



GYNECOLOGY. 



may be indirectly obliterated by closure of the vaginal orifice, 
thus making the vagina a part of the urinary reservoir. A 
ring of tissue two centimeters broad is removed from the vaginal 
orifice. In the dissection the parts should be kept on the 
stretch and the tissue should be dissected from above down- 
ward. A sound in the urethra and a finger of an assistant in 
the rectum will greatly facilitate the denudation of the anterior 
and posterior walls of the vagina. The sutures should be passed 




Fig. 205. — Introduction of Vaginal Sutures. 



from below upward and from above downward, exercising 
the greatest care that neither rectum, bladder, nor peritoneum 
shah be perforated by the sutures. The denuded surfaces 
should be brought in accurate apposition and the overlapping 
of freshened surface with mucous membrane or skin should 
be strictly avoided. This procedure, while it affords a means 
of reheving incontinence of urine in otherwise desperate cases, 



TRAUMATISMS. 



235 



has many disadvantages. Impregnation is no longer possible; 
coition can be practised only when obliteration has occurred 




Fig. 206. — Section Showing Projection upon Vesical Surface. 




Fig. 207. — Self-retaining Catheter. 




Fio-. 20S. — Vesico-uterine Fistula. 



high in the vagina. The menstrual blood .not infrequently 
excites violent cystitis, resulting in pyelonephrosis and the 



236 



GYNECOLOGY, 



formation of vesical calculi. The urine may cause metritis 
or tubal, ovarian, and even peritoneal inflammation. Recto- 
vaginal fistula has been made to supplement this operation 
when the neck of the bladder has undergone such injury as to 
render the patient unable to retain the urine. The majority 
of such cases have been unsuccessful, owing to the irritation 
of gas and feces and the inclination of the fistula to close. 
284. Urethrovaginal fistula is very infrequent. It is char- 




Fig. 209. — Colpocleisis. 



acterized by the discharge of urine into the vagina during 
micturition. The flap-splitting operation affords the most satis- 
factory method of closing it. 

285. Vesico-uterine fistula permits the escape of urine 
through the external os. It may result from a slough follow- 
ing a tedious labor, and from lacerations of the cervix when 
the tear has extended through the anterior lip. The tear may 



TRAUMATISMS. 



237 



have been incomplete, not extending through the os, or the 
fissure may have healed with the exception of the communica- 
tion between the bladder and cervix. The only condition 
with which such a fistula can be confused is the uretero -uterine. 
The latter fistula is rare. Upon injecting the bladder with 
a colored fluid (a solution of pyoktanin) its emergence from 
the OS demonstrates the presence of a vesical fistula; the con- 
tinuance of clear fluid, a ureteral. In an opening of consider- 




Fig. 2IO. — Closure of Fistula after Its Exposure b}^ Incision through Anterior 

Vaginal Fornix. 



able size the sound will pass directly into the bladder, where 
it can be recognized by another inserted through the urethra. 
Treatment. — The fistula may be exposed by dilating the 
cervix with a laminaria tent. In a uretero-uterine fistula this 
procedure would be accompanied with renal pain, nausea, and 
vomiting, due to the obstruction of urine from the kidney 



238 



GYNECOLOGY. 



corresponding to the affected ureter. The fistula may be 
denuded and closed from the cervical canal, but the opera- 
tion is attended with difficulty. The preferable procedure is 
to cut through the anterior fornix of the vagina and dissect 
the bladder from the cervix, when the opening can be exposed 
and sutured; the vaginal wound is subsequently closed with 
silk or catgut. It is desirable that the peritoneum should 
not be opened, though its incision, with proper precautions, 
does not materially affect the result. When the bladder-wall 
is thin, Herr advises cutting through the cervix and reinforcing 
the bladder-wall with cervical tissue. Sanger split the cervix 
of a patient in whom the sinus opened laterally, sutured the 




Fig. 211. — Fistula Closed into Va- 
gina. Uterine Opening Re- 
mains, Which Will Close of 
Itself. 




Fig. 2 12. — Section Showing Suture 
for Hysterocleisis. 



side on which the fistula occurred, as in an Emmet operation, 
and then sutured the other side. 

286. Hysterostenosis or hysterocleisis (Fig. 214), the denu- 
dation and suturing of the cervix, is possible, but the menstrual 
flow may produce serious cystitis, and contraction of the fistula 
may result in severe pain and distress during menstruation. 

287. Vesico-uterovaginal (Cervical) Fistula. — A portion of 
the cervix, with a considerable portion of the vaginal septum, 
may be destroyed, and the remaining walls may be so thin as to 
render its closure difficult or dangerous, owing to proximity of 
the peritoneum. In such cases the anterior lip of the cervix 



TRAUMATISMS. 



239 



(Fig. 215) may be denuded and turned into the bladder, using 
it as a plug to fill up the opening. 

When the fistula has developed at the expense of the anterior 
cervical lip to such an extent that it will not afford sufficient 
structure to close the opening, the posterior lip may be freshened 
and utilized (Fig. 216). This procedure necessarily produces 
disturbance because of the continuance of menstruation. A 




Fig. 213. — Closure of Fistula within Cervical Canal after Splitting Cervix. 



preferable method is to separate the vesical wall from the cervix 
and secure sliding flaps, which can be closed as in figure 217. 

288. Ureterovaginal-ureterocervical Fistulae. — Lesions of the 
ureter are less frequent than the other forms of fistula. Par- 
ticipation of the ureter in the vesicovaginal opening is much 
more frequent. Uretero vaginal fistulae are more frequently 
the result of injuries sustained during the performance of hys- 
terectomy. The diagnosis has been considered. (See Section 



240 



GYNECOLOGY. 



274). The cervical fistula is very rare. The thickened ureter 
can generally be traced to the cervix by the finger in the vagina. 
Treatment. — Relief from the discomfort produced by these 
fistulas may be accomplished by resort to one of several methods, 
viz. : 

1. Anastomosis through the vagina. 

2. x\nastomosis through the abdomen. 




Fig. 214. — -Hysterocleisis. 



3. Ligation of the ureter. 

4. Introduction of the ureter into the rectum or colon. 

5. Nephrectomy. 

Anastomosis through the vagina is accomplished by first estab- 
lishing an artificial vesicovaginal fistula alongside the ureter. 
This opening, and the ureter opened for the distance of nearly 
two centimeters of its intraparietal border, are prevented from 
closing by the subsequent daily use of the sound. After perma- 
nent cicatrization has taken place, the vesicovaginal fistula. 



TRAUMATISMS. 



241 



which now includes the ureteral, is closed by denudation and 
suturing the new surfaces (Simon). The vesicovaginal fistula 
may be formed by an oval incision. A small elastic catheter 
can be passed into the bladder, through the urethra, from it 
through the fistula into the vagina and then into the orifice of 
the ureter. With the patient in the genupectoral position the 
vaginal mucous membrane is denuded around the fistula. To 
close the opening, the sutures are placed parallel to the catheter, 
which is left in place for several days (Landau) ; or a buttonhole 
incision may be made, removing two centimeters of the vesical 
mucous membrane in the direction of the ureter, the vesical and 
vaginal mucous membranes are sutured to prevent closure, and 
a catheter is introduced into the bladder through the urethra and 
into the orifice of the ureter through the vesical fistula. An 




Fig. 215. — Anterior Lip of Cervix 
Utilized to Close the Fistula. 



Fig. 216. — Vesico-uterovaginal Fis- 
tula in which the Posterior Lip 
of the Uterus is L^tilized to Close 
the Opening. 



annular denudation is made about the fistula, leaving immedi- 
ately about it a zone of mucous membrane three millimeters in 
diameter. After suturing, the fistula with intact mucous mem- 
brane is turned into the bladder, where it forms a gutter-like 
depression, into which the ureter opens (Schede). X. O. Werder, 
in a case of double ureterovaginal fistula following hysterectomy, 
made a transverse incision through the anterior vaginal wall 
into the bladder. The vaginovesical edges of the upper portion 
were sutured together, while the inferior border was united to 
the posterior vaginal wall, making a diverticulum to the bladder 
which controlled leakage. 

All these methods employ the formation of an artificial 
vesicovaginal fistula, which must ultimatelv contract. As the 

16 



242 



GYNECOLOGY. 




ureter is a distinct canal, capable of being dissected out of its 
bed, there seems no reason why it should not be loosened from 
cicatricial adhesions, drawn down, and introduced through an 
opening in the vesicovaginal septum. This procedure is appli- 
cable to either vaginal or cervical fistulse of this canal. In order 
to prevent compression of the ureter a portion of the bladder- 
wall should be excised. The ureter is introduced into the 
bladder, the wound is carefully closed with sutures introduced 

to fix the wall of the ureter 
and thus insure its reten- 
tion. Care should be exer- 
cised that the ureter is not 
compressed, nor much, if 
any, of its surface left un- 
covered in the vagina. In 
ureterocervical fistulae the 
cervix should be split until 
the orifice of the ureter is 
exposed, when that struc- 
ture can be drawn down 
and union accomplished in 
the manner just described. 
Obliteration of the vaginal 
orifice has been done after 
the establishment of a ves- 
icovaginal fistula, but such 
a course is both unnecessary 
and undesirable. 

Anastomosis through the 
abdomen may be preferable 
in a narrowed cicatricial 
vagina, or when the lower 
extremity has undergone 
inflammatory changes or is 
so embedded in exudation 
that it can not be readily 
brought down. Through 
the ordinary incision for 
abdominal section the intestines are drawn aside, exposing 
the line of the ureter. In ureterovaginal fistula its situation 
can the more readily be recognized by the introduction of a 
catheter prior to the abdominal incision. The peritoneum is 
opened, the ureter is raised, its proximal portion is tied and 
dropped back, and the central end is introduced through an 
incision into the bladder and secured by sutures, as in the vaginal 
method. The anastomosis with the bladder should be on the 




■X 



Fig. 217. — Vesical Wall Loosened and Su- 
tured. Vaginal Wall Sutured in Oppo- 
site Direction. 



TRAUMATISMS. 



243 



corresponding side of the pelvis, and with as Httle tension upon 
the canal as possible. Should the ureter be so short as to cause 
tension in reaching the bladder, the latter should be drawn up 
and anchored by a few stitches to the side of the pelvis, so that 
no traction shall be made upon the ureter. If the ureter it too 
short to permit of its introduction into the bladder, and the 
condition of the patient is unfavorable for a complicated opera- 
tion, the ureter may be tied with a double ligature and dropped 
back. The urine accumulates in the pelvis of the kidney until 
the pressure equals that of the blood, when secretion ceases. 
The ureter may also be introduced into the rectum or colon. 
The ureter should pass through the bowel obliquely. However, 
this procedure is very likely 
to be followed by serious 
conditions in both the uri- 
nary tract and the intes- 
tine. In the former, in- 
fection and suppuration of 
the pelvis of the kidney 
are prone to follow. The 
presence of urine frequently 
causes irritation and in- 
flammation (colitis or proc- 
titis) of the intestine. 

Nephrectomy is advisa- 
ble when the long duration 
of the fistula has resulted 
in extension of infection to 
the pelvis of the kidney, 
and careful examination 
has disclosed that the other 
kidney is capable of carry- 
ing on the work of both 
organs. 

289. Accidents of the Operation and Results. — Primary hem- 
orrhage of a serious character may result from an unusually large 
uterine artery, from vascular walls, or from injury of the vesical 
mucous membrane. Either compression or suture is the best 
means for its control, but its occurrence imperils the result of 
the operation. 

Secondary hemorrhage may take place between the third and 
fifth days, and should be controlled by the tampon. It may 
occur into the bladder, and may be discovered only after that 
organ is filled with clot. It gives rise to violent tenesmus, and 
its decomposition will be extremely prejudicial to the success of 
the operation. When it can not be removed by irrigation, inject 




Fio-. 218- 



-Operation for 
Fistula. 



Uretero vaginal 



244 



GYNECOLOGY. 



a solution of pepsin or enzymol. If this procedure fails to 
afford relief, the urethra should be dilated and the clot broken 
up and removed with a blunt curet. If hemorrhage continues, 




Fig. 219. — Vaginal Implantation of the Ureter into the Bladder. 



it will be necessary to remove the sutures and search for the 
bleeding vessel. 

Inclusion of a ureter will cause nausea, vomiting, lumbar pains, 
and fever. The suspected suture should be immediately removed. 



TRAUMATISMS. 



245 



Peritonitis can result from injury during the denudation 
or suturing, or from infection, when proper precautions have 
not been observed, or when there is coexisting pyeHtis or cystitis. 

Calculi and calcareous concretions have formed upon silver 
wire, silk, or even catgut sutures. 

The results of the operation are generally most satisfactory. 
Death is of very infrequent occurrence. 

290. Rectovaginal Fistula. — The methods of treatment sug- 
gested (Section 276) are equally applicable to the fecal fistulas. 




Fig. 220. — Abdominal Transplantation of Ureter for Uretero vaginal Fistula. 



The last two methods, flap-splitting and flap-formation, are 
probably effective and most generally applicable in the great 
majority. 

In a small fistula a curvilinear or triangular trap-door may 
be raised, including the fistulous orifice; the opening in the 
rectal Avail is closed by very fine (eye) silk, Avhich has been 
previously sterilized, or by chromicized catgut; one or several 
Lauenstein sutures may be used, being careful not to enter the 



246 GYNECOLOGY. 

rectum. The vaginal flap is then secured with silkworm-gut 
sutures. In large fistulae a sagittal incision with lateral flaps 
is most satisfactory. The sutures are introduced as previously 
described. Flap-formation is very serviceable in closing rectal 
fistulse of considerable size; fiap-transplantation is rarely suc- 
cessful. 

291. An ano vulvar fistula can be closed from the vagina or 




Fig. 221.— Ureteral Anastomosis. 

perineum. Such a fistula is incised through its track, cureted, 
and the entire sinus closed by sutures. It is generally better to 
extend the incision to, but not through, the sphincter, and to 
close the rectal or anal surface with sutures from the perineal 
side, when failure to unite will not endanger the future value 
of the sphincter and will enable the operator to secure union 



TRAUMATISMS. 



247 



by granulation through gauze packing. Small fistulae near 
the vulvar outlet can be closed as a part of the operation of 
perineorrhaphy. 

292. Preliminary and After-treatment. — The bowels should 
be thoroughly evacuated by repeated purging for two or three 
days. During the same period vaginal douches should be 
given, and a thorough scrubbing of the vagina with a solution 
of creolin and soap should immediately precede the operation. 
However, no operative procedure for closing a fistula should 
be entered upon until careful rectal examination has demon- 
strated the absence of a possible rectal stricture as its cause. 
For several days prior to the operation, and for at least a week 





Fig. 222. — Sagittal Incision for 
Rectovaginal Fistula. 



Fis 



3. — Lauenstein Suture in Recto- 
vaginal Fistula through Rectal Wall. 



subsequently, the patient should be kept upon an animal broth 
diet, and the use of milk should be prohibited. The opera- 
tion should be preceded a few hours by thorough irrigation 
of the rectum, and continuous irrigation should be practised 
during it. After the third day the bowels should be moved 
each alternate day. The sutures of silk should be removed 
upon the eighth day; silkwoxm-gut or silver wire may be per- 
mitted to remain for fifteen days. The patient should be con- 
fined to bed the greater part of three weeks, and the bowels 
should not be permitted to become constipated for a month. 
293. Entero vaginal fistulae have been cured by cauteriza- 
tion or by denudation and suture from the vagina, but closing 



248 GYNECOLOGY. 

the fistulous intestine through the open abdomen is preferable, 
when the vaginal opening will need no further consideration. 

294. Lacerations of the pelvic floor are a frequent lesion of 
parturition, and can occur from within outward through the 
vagina and vaginal portion of the perineum, leaving its in- 
tegumental covering intact. The injury is a separation or 
tearing-off of the muscular fibers from the sides of the vagina. 
Generally, the tear takes place through the integument of the 
perineum, sometimes it may extend through the entire struc- 
ture, the sphincter, and up the rectovaginal septum. Not 



^^^=^ 


y 


V --■^^^^: 


,.y;> 


•^■4-ffL____^ 




'^^m"^ 


'^^==-^_. 




:'■ V V 


-^'' 


'X 




""'*"\-. 






* 




! ■' 





Fig. 224. — Rectal Wall Closed by Transverse Line of Sutures; Vaginal by 
Vertical Line of Sutures. 

infrequently it will be found that the injury has been quite as 
deep, but on one side of the rectum and anus, and leaves both 
intact. Less frequently it will thus extend on both sides of 
the anus. 

Naturally, the influence upon the subsequent appearance 
and function of the parts must vary with the extent and direc- 
tion of the laceration. A slight laceration, which involves 
only the anterior portion of the perineum, may heal without 
producing much, if any, deformity. A deeper laceration, by the 
action of the trans versus perinei muscles, permits the vaginal 



TRAUMATISMS. 



249 



orifice to stand open, and presents a triangular appearance. 
Tlie failure of the bulbocavernosi muscles longer to antagonize 
the coccygeus permits the anus to be drawn back. 

Laceration through the sphincter necessarily causes loss of 
control of the bowel-contents. (Fig. 226.) 

The deep laceration to one side of the anus leaves the levator 
ani unantagonized, and the parts are draAvn to the opposite side ; 
when the tear extends upon both sides, the anus is depressed 




Fig. 225. — Rectovaginal Fistula Closed 



tion of Perineorrhaphy. 



and drawn backward. The vulva stands open, and we can 
look into the vagina from three to five centimeters. 

295. Causes. — Injuries of the pelvic floor may arise, first, 
from conditions inherent in the mother; second, in the child; 
and third, in the course and management of the labor. Of 
the first class may be (a) too great or too slight an inclination 
of the pelvis, Avhich renders the mechanism of the fetal head 
imperfect; (6) a small vulvar orifice with rigid muscles, or a 



250 



GYNECOLOGY. 



large amount of fat in the perineum ; (c) high or anterior situation 
of the vulva, making a long perineum, over which the child's 
head must be extended. 

Second, laceration may result from excessive size of the 
fetal head and shoulders or from relative disproportion to 
the size of the mother. 

Third, laceration may result from (a) either too rapid or 
too tedious labor ; (b) vertex presentations when rotation occurs 




Fig, 226. — Rupture of Perineum into Rectovaginal Septum. 



into the hollow of the sacrum and an occipitoposterior position 
presents a longer diameter of the head at the outlet; (c) face 
presentations, in which the longest diameter of the fetal head 
presents ; (d) either incomplete or excessive flexion ; (e) faulty 
manual or instrumental interference. 

296. Degree or Extent. — Lacerations of the pelvic floor 
may be incomplete or complete, and are generally divided 



TRAUMATISMS. 



251 



into four degrees: First, a tear through the fourchet and to a 
slight extent in the perineum; second, to the sphincter. These 
form the incomplete lacerations, while the complete are: third, 
the tear extending through the sphincter; and, fourth, up the 
rectovaginal septum. A rare form of laceration is the central 
rupture, in which the fetus passes through the perineum with- 
out tearing either the sphincter or the vulva. 

297. The results of the injury are necessarily dependent 




Fig, 227. — Cystocele. 



upon its extent. The immediate effects are induced by the 
action of the injured or antagonistic muscles. The cicatricial 
tissue produces certain reflex nervous phenomena, which, 
however, are insignificant compared to the mental influence 
exerted by fecal incontinence. The laceration causes defective 
involution of the vagina and uterus, the defect in the muscular 
junction of the pelvic floor weakens the action, and consequent 



252 GYNECOLOGY. 

resistance of the pelvic diaphragm. The constantly varying 
pressure of the bladder and rectum, the increased abdominal 
pressure consequent upon straining at stool, and the abnormally 
heavy uterus lead gradually to displacement downward of that 
organ, or, if it is fixed by the condition of its pelvic attachments, 
to extrusion of the anterior and posterior walls of the vagina, 
and their consequent weight will produce hypertrophic elon- 
gation of the cervix. Thus we have cystocele (prolapse of the 



Fig. 228. — Rectocele. 

anterior vaginal wall, and with it the bladder), rectocele (pro- 
lapsed posterior wall), partial or complete prolapse of the vagina, 
with elongation of the cervix, or procidentia, consequent upon the 
increased weight of subinvoluted organs and the diminished 
support resultant from the lesion under discussion. 

298. Treatment.— The proper course of procedure is to so 
repair the injury as to restore as nearly as possible the normal 



TRAUMATISMS. 253 

condition of the pelvic floor. In slight lacerations restoration 
will be secured by keeping the patient quiet and the parts clean. 
The operative treatment may be primary, intermediate, or sec- 
ondary. 

299. By primary operation is understood the immediate repair 
of the laceration, or at least within twelve hours. The tear pre- 
sents a large, raw surface, and is frequently found with ragged, 
irregular edges. The vagina may have been torn and the soft 
parts pushed off until the perineum has split either through 
the sphincter or to one or both sides of the anus. The method 
of repair will depend upon the nature and extent of the lesion. 
The necessary instruments will be found in an ordinary pocket 
case — scissors, dissecting forceps, a needle-holder, and long and 
short curved needles. The suture material may be silkw-orm-gut, 
catgut, silk, or silver wire. The patient should be placed upon 
her back across the bed, or upon a table, while an assistant 
holds each leg, flexed upon the abdomen. As the parts are, 
benumbed by the stretching to which they have been subjected, 



Fig. 229. — Right and Left Curved Scissors. 

an anesthetic may be omitted ; but if the patient is very nervous, 
one should be employed. A rubber pad or a piece of mackintosh 
should be placed beneath the patient to prevent soiling of the 
bed and to direct the current of irrigating fluid into a receptacle 
upon the floor. Compress the uterus and cleanse it and the 
vagina of clots; cleanse the external surface with a disinfectant 
fluid, after having trimmed the vulvar hair in order to keep it 
from embarrassing the procedure. Place a pad of gauze or ab- 
sorbent cotton beneath the cervix to keep the vagina free from 
blood. Trim smooth the ragged edges of the tear and proceed 
to suture. Fine chromicized catgut is preferable, because it will 
not have to be removed, and it produces less annoyance during 
the care of the patient than does either silkworm-gut or silver 
wire. In slight lacerations and vaginal tears the use of the con- 
tinuous suture is satisfactory. In extensive laceration inter- 
rupted sutures offer advantages. Precautions should be exer- 
cised to leave no dead spaces in which blood may accumulate. 



254 



GYNECOLOGY. 



become infected, and produce sepsis. In a double tear which 
extends upon both sides of the rectum the needle should be 
entered from above, brought out in the sulcus, reentered, and 
carried upward through the vaginal mucous membrane, so that 
each suture lifts up the tissue. Care should be exercised to 
restore the position of the levator ani muscles by bringing their 
torn ends back in position. So far as possible the sutures should 
be brought out in the vagina, as they thus produce less pain. 




Fig. 230. — Incomplete Rupture of the 
Perineum. 



Fig. 231. 



-Simon-Hegar Method of 
Denudation. 



The necessary perineal suturing may be with continuous suture, 
inclosing but little of the skin. 

In laceration of the sphincter make sure that the ends of 
the divided muscle are secured and coapted by the suture. 
When the tear has extended into the rectovaginal septum, the 
sutures may be brought out and tied in the rectum, or, what is 
probably preferable, the Lauenstein suture may be employed, 
with buried catgut. 

300. The advantages of the primary procedure are : first, if 
the operation is successful, the patient is spared the necessity of 



TRAUMATISMS. 



255 



a subsequent operation; second, with proper precautions she is 
much less Hkely to suffer from infection, and convalescence is 
expedited; third, the sequelae of unrepaired injuries are avoided. 
301. Contraindications. — The primary operation is contra- 
indicated when the patient has been exposed to a prolonged labor 
and the tissues have undergone extensive fraying or bruising 
through prolonged manual or instrumental interference. It is 
also contraindicated when there is reason to believe that the 
wound has been exposed to some virulent infection. Even in 
such cases, when the laceration extends through the sphincter, 




Fig. 232. — Sutures Introduced to Close the Wound. 



the anus and rectal wall should be sutured, in order to afford 
security to the contents of the bowel. 

302. The intermediate operation is performed any time from 
twelve hours to a week following the labor. The delay may be 
occasioned by want of proper material at hand, or it may be 
due to the condition of the patient, who is suffering from such 
profound shock that it will seem unwise to resort to any imme- 
diate procedure. With the delay, the surface becomes covered 
with plasma, and, later, granulations form, the surface is irritated 



256 



GYNECOLOGY. 



by the lochia, and, unless strict antisepsis has been practised, 
it becomes an excellent culture field. Prepared as in the primary 
procedure (Section 299), the vagina is cleaned, gauze is applied 
to restrain the uterine discharge, the wounded surface is scraped 
with a curet or knife, the edges are trimmed, and the parts are 
sutured. The results are not usually very satisfactory. 

303. Secondary Operation. — This operation is preferably not 
performed for at least two months subsequent to delivery, in 





1 ^ ■ 




I 




A 




=^_-^--rrz^ \ 




'^ '/£.>--' -z 'o 3 


.__ 


-ZZ', 


2^^s^ 


f" 




;^ 



Fig. 233. — Garrigues' Modification of the Hegar Operation. 



order to permit involution and cicatrization to become accom- 
plished. In preparation, particularly when the tear is complete, 
the bowels must be thoroughly evacuated. Castor oil, a saline, 
or compound licorice powder should be given several days or a 
week before the operation and repeated at intervals of from 
twenty-four to forty-eight hours, in order to insure thorough 
evacuation of all hard scybalous masses. The diet should con- 



TRAUMATISMS. 



257 



sist largely of animal broth, while milk should be absolutely 
excluded. The evening and morning before the operation the 
lower bowel should be cleansed with large enemas. The last 
enema should be given at least three hours before the time fixed 
for the operation. Patients should be prepared (Section 119), 
and the following instruments sterilized: a scalpel; right and 
left curved scissors, as well as scissors curved on the fiat ; three 
double tenacula; eight pressure forceps; one long, rat-toothed 
dissecting forceps; a needle-holder; and two long and two short 





Fig. 234. — Upper Part of Wound 
Closed; Last Sutures Introduced. 



Fig. 2 2,>. — Wound Completely 
Closed. 



curved needles, all threaded with carriers. The suture material 
may be silk, silkworm-gut, catgut, or silver wire. In extensive 
laceration the silkworm-gut is preferable, for the reasons, first, 
that it, being more pliable, causes less pain during convalescence 
than wire, and, second, it is much less likely to become infected 
than either silk or catgut. 

Incomplete laceration (Fig. 230) may be repaired by a simple 
denudation of the torn surfaces (Fig. 231). As cicatrization has 

17 



258 



GYNECOLOGY. 



resulted in contraction, it is necessary to extend the denudation 
of the vagina above the scar tissue. The further backward the 
rent extends, the higher into the vagina the denudation must 
be carried. The Hne of denudation extends posteriorly from the 
junction of the mucous membrane and skin at the top of 
the old posterior commissure across in front of the anus to a 
corresponding point upon the opposite side, while an angle ex- 
tends up the vagina above the tear. The completed denudation 





Fig. 236. — Lauenstein Suture. 



Fig. 237. — Rectum and Vagina Closed 
with Lauenstein Suture. 



presents a resemblance to the body and wings of the butterfly, 
and is designated the Simon-Hegar denudation. (Fig. 232.) 

The sutures are introduced about three millimeters from the 
margin of the wound, buried beneath the denuded surface, and 
brought out at a corresponding point upon the opposite surface. 
The sutures in the vaginal angle are first secured, and then the 
perineal (Fig. 232). The sutures when tied produce less discom- 
fort than if secured by compressing perforated shot upon their 



TRAUMATISMS 



259 



ends. The quill or bar suture was formerly much favored. It 
consisted of a quill placed in the loop of a double suture upon 
one side, the ends being tied over a second quill upon the oppo- 
site side, or the ends of a suture were passed through openings 




Fig. 238. — Hildebrandt's Method of Suturing. 



in a bar and secured by shot. The two quills or bars served 
for all the sutures, while the skin edges were united by super- 
ficial sutures. The suture caused so much pain that it has been 
largely discontinued. 



260 



GYNECOLOGY. 



A slight exaggeration of the denudation just described can be 
applied to the restoration of a complete laceration. The sutures 
must then be vaginal, rectal, and perineal. The latter are intro- 
duced after the former are placed. The rectal sutures of catgut 
are brought out into that canal. Care must be exercised in the 
introduction of the first perineal suture that it shall accurately 
bring the ends of the sphincter ani in apposition. 

Garrigues modified the Hegar operation by the following 
procedure (Fig. 233): According to the extent of the laceration 
and relaxation of the vagina and perineum, the vagina is seized 
with a double tenaculum at a point in the median line more or 




Fig. 239. — Hildebrandt Suture Closed. 



less removed from the cervix. A point upon each labium majus 
is secured at such a distance from the clitoris as to permit of 
coition. The parts are rendered tense, the points are connected 
by an incision, and the intervening triangular surface is denuded. 
This denudation is carried downward to the margin of the skin 
and mucous membrane. With the vulva separated, the denu- 
dation presents a triangular surface. 

The denudation is most rapidly accomplished by introducing 
one blade of curved scissors beneath the membrane at the point 
determined upon in the one labium and carrying it around the 
vaginal outlet to a similar position opposite. The central part 



TRAUMATISMS. 



261 



of this incision is picked up with forceps, cicatricial bands cut, 
and the finger pushed beneath this flap to the desired height. 
The tissues are pushed off laterally, and the triangular section 
is removed. It has the advantage that it is more than a denu- 
dation. It is a resection, and, therefore, permits the more accu- 
rate union of fascia and muscular structure. 

The sutures are introduced from above downward, about six 
millimeters apart, deep and superficial alternating, the latter 




Fig. 240. — Heppner's Figure-of-8 Suture. 



passing only through the edges of the mucous membrane. The 
four upper sutures are transverse; the remainder dip down- 
ward at the central portion, and, when tied, lift up the relaxed 
wall. The sutures are thus introduced and tied one after 
another until the remaining denuded surface forms an ellipse, 
the upper and lower borders of which are of equal length. (Fig. 
234.) Then a silkworm-gut suture (10) one centimeter above 
the posterior commissure is carried deeply beneath the wound 



262 



GYNECOLOGY. 



two-thirds the width of the denudation, and emerges at a similar 
point upon the opposite side. A second suture (ii) is inserted 
midway between this suture and the outer margin; passing 
beneath the denuded surface it emerges upon the vagina to 
the left of the median line, is reintroduced, and comes out 
equally distant from the first suture upon the right side. The 
last suture, introduced near the extremity of the denuded 
surface, appears in the vagina midway between the second 
suture and the external denuded angle, reenters upon the op- 





Fig. 241. — Martin Suture to Close the 
Rectal Opening. 



Fig. 242. — Martin Suture Con- 
tinued. 



posite side, and emerges upon the right labium. These three 
sutures are all introduced and the surface is irrigated, when 
they are secured. 

In my judgment, the employment of the continuous chromic 
catgut suture is far more satisfactory. It can be so introduced 
as to lift up the pelvic floor, and should include the edges of 
the levator ani muscle and the overlying fascia. If the floor 
is much relaxed, the muscle and fascia can be sutured sepa- 
rately and the mucous surfaces be closed over it with a con- 



TRAUMATISMS. 



263 



tinuous suture. This method of suturing greatly expedites 
the operation and has the advantage that it leaves no sutures 
(Fig. 235) to be removed. 

Lauenstein' s Method of Sutviring. — This method of intro- 
ducing the sutures was devised to prevent their infection by 
the rectal and vaginal discharges. The sutures, of catgut or 
fine silk, are introduced in the bleeding surfaces, including 
about five millimeters of the tissue intervening between the 




Fig. 243. — Denudation for Freund's Operation. 



borders of the rectal and vaginal mucous membranes respec- 
tively. (Fig. 236.) These are necessarily buried sutures. 
The remaining portion of the denuded surface is closed by 
silver wire from the perineum. (Fig. 237.) 

■ Hildehrandt makes the denudation trefoil in shape. (Fig. 
238.) The sutures are for the most part cutaneous. The 
vaginal sutures are first introduced ; next the rectal, and, finally, 



264 



GYNECOLOGY 



the perineal. (Fig. 239.) This method" of suturing obhterates 
dead space and decreases the danger of abscess. 




Fig. 244. — Sutures Inserted in Rectal Wall and Lateral Vaginal Angles. 





Fig. 245. — Vaginal Angles and Rectal 
Wall Closed. Suture in Place for 
Perineum. 



Fig. 246. — Denudation Completely 
Closed. 



Heppner accomplishes the same object with a figure-of-8 
suture, which closes both vaginal and perineal surfaces. (Fig. 
240.) 



TRAUMATISMS. 



265 



Martin more rapidly, and with a less complicated pro- 
cedure, meets the difficulty. fFig. 241.) He, with a con- 
tinuous catgut suture, unites the intestinal wound from the 
rectal surface; when he reaches the anus, with the same suture 
in a contrary direction he superimposes a layer up to the superior 
angle of the vagina, and if the denudation is deep, a third layer 
before the vaginal and perineal surfaces are united. (Fig. 242.) 

Frennd has emphasized the necessity of securing such a 




Fig. 247. — Emmet's Operatic 



Surface Denuded and Lateral Sutures in 
Place. 



denudation as would reproduce the original appearance of 
the tear. This, if there is a cicatrix, Avhich presents the appear- 
ance of 00, the laceration from which it has contracted may 
be represented by figure 243. He incises the posterior column 
of the vagina at a certain distance from the scar and carries 
the bistoury backward along the sides of this column, circum- 
scribing the cicatrix in the vagina and upon the labia majora, 



266 GYNECOLOGY. 

and completes the denudation as in an ordinary operation. 
The Hne which corresponds to the rectum is sutured, then 
each edge of the posterior vaginal column is united to the ex- 
ternal margin of the denuded surface. The union of the lines 
forms the vulvar and perineal surfaces. 

Emmet's operation is of especial value in relaxation of the 
posterior vaginal wall, and its purpose is to expose the fascia 
and so to introduce the sutures as to fold in the slack and lift 



s, 



-'*"'' ^ 




■# 



Fig. 248. — Emmet's Operation. Lateral Angles Closed and Perineal Suture 

Introduced. 

Up the perineum, bringing the parts more completely under 
the control of the levator ani muscle. With the labia separated 
by the hands of assistants, the summit of the protruding recto- 
cele is seized with a double tenaculum; two other tenacula 
are placed one upon each of the caruncula, and a fourth upon 
the commissure of the vulva. When these are separated, 
they constitute a quadrilateral surface. These instruments 
are employed to render the parts tense, and the lines between 



TRAUMATISMS. 



267 



them are employed as the boundaries of the denudation. The 
intervening surface is completely denuded. (Fig. 247.) The 
sutures are then introduced in triangles, beginning in the sulcus 





Fig. 249. — Emmet's Operation Fig. 250. — Emmet's Operation for Com- 

Completed. plete Laceration. 



Correct^ 




Fig. 2 5 1. ^Suture to Unite the Ends of the Sphincter. 



268 



GYNECOLOGY. 



Upon either side. The sutures introduced form a double triangle ; 
a suture joins the summit of denudation upon each side with 
the apex of denudation of the posterior column. This is called 
the crown stitch. (Fig. 248.) A number of perineal sutures 
are then used. By this method the majority of the sutures 
are within the vagina. The tying of the sutures lifts up the 
pelvic floor and brings the posterior segment of the pelvic 
floor more closely in contact with the anterior. (Fig. 249.) 




Fio-. 



252. 



-Outerbridge's Suture. 



Noble modifies this operation by carrying his denudation higher 
upon the posterior column, by splitting the fascia and exposing 
the levator ani muscles. In suturing, he pulls out the muscle 
and secures it with not only the lateral, but also the central 
sutures, or those below the crown suture. This brings the 
muscles in contact in front of the rectum and insures a strong 
support to the pelvic floor. 



TRAUMATISMS. 



269 



Emmefs operation for complete laceration has for its first and 
principal aim the restoration of the sphincter ani. The first 
suture is introduced and brought behind the ends of the torn 
sphincter, which have been carefully exposed in the denudation. 
(Figs. 250 and 251.) As the suture is drawn up and secured, 
the precaution is taken to draw up and place in position the 
ends of the sphincter, so that they may be firmly secured. The 
remaining sutures appose the denuded surface of the perineum. 




3!^ 



e;^::.^ 




Fig. 2^2>- — Clf\"t'land's Suture. 



Fig. 254. — Jjfiiudatiun for Martin's 
Operation. 



Oiiterhridge modifies Emmet's operation in that he uses but 
three sutures. The first, of medium-sized catgut, by means 
of a needle threaded with a carrier loop, is passed from the end 
of the central undenuded portion to the summit of the lateral 
denudation upon either side. It is thrown over the pubes and 
a silver wire suture is passed from the highest point of the 
denudation upon one labium ma jus beneath the whole wound 
across to the corresponding point upon the opposite side. (Fig. 
252.) The catgut suture is now tied and its ends are passed 



270 



GYNECOLOGY. 



downward to penetrate the skin upon each side one centimeter 
from the lowest point of the denudation. This suture tied, 
the silver wire is secured. The latter suture is removed upon 
the eighth day. 

Cleveland uses a figure-of-8 suture of catgut. (Fig. 253.) 
The first suture enters the skin six millimeters from the wound 
margin and midway between the posterior commissure and the 
summit of the denudation in the left labium, passes deeply across 






'1^^ 



Fig. 255. — Dudley's Operation with 
Interrupted Sutures. 



Fig. 256. — Dudley's Operation Com- 
pleted. 



between the denuded surface and rectum, embracing the muscles, 
and emerges upon the right labium six millimeters from the 
wound margin and midway between the posterior commissure 
and the point corresponding to its entrance, is reintroduced at 
a similar point upon the left labium, and emerges upon the right, 
directly opposite its original entrance. 

The second suture follows a similar course. It enters the left 
labium near the summit of denudation, is buried beneath the 



TRAUMATISMS. 



271 



edge of the denudation to the center of the vaginal column, then 
passes downward, and emerges upon the right labium midway 
between the summit of denudation and the exit of the first suture. 
It is introduced upon the left labium at a corresponding point, 
passes across its former course, follows the border of the right 
sulcus, and emerges beneath the right summit. 

A suture of wire or silkAvorm-gut, for support, is passed 
throuo:h the left labium about eight millimeters above the 




^' 




Fig. 257. — Vaginal Surfaces United; 
Perineal Sutures in Place. 



Fig. 258. — Bischoff's Operation. 



denudation, and about the same in the anterior vagina and the 
right labium. 

A. P. Dudley makes a quadrilateral denudation with angles 
at the summit of the rectocele, laterally at the caruncula, and 
at the posterior commissure. The denudation removes only the 
mucous layer, preserving the submucous. (Figs. 255 and 256.) 
The finger is introduced into the anus and the first suture is 



272 



GYNECOLOGY 



passed downward and forward to the median line, where it is 
brought out, reintroduced three milhmeters from its exit, and 
carried upward and backward to emerge upon the other side 
of the vagina. This suture is tied, and acts as a fixed point from 
which to work. The remaining sutures, of juniper catgut, are 
made over and over and are introduced in a direction similar 
to the first, taking care to push up the rectocele with a director 




Fig. 259. — Splitting Vaginal Wall Preparatory for Suture. — {Andrews.) 



as each stitch is tightened. As the outlet is approached the 
angle of the sutures is decreased, until, when abreast of the hymen, 
they are passed transversely. At this point the inside work is 
finished and the suture is made fast. A number of buried sutures 
are passed through the fibers of the separated central tendon. 
These extend to the extremity of the rent, when, with a con- 
tinuous suture, they return to the point where the deep sutures 
began. After examination of the wound for bleeding points or 



TRAUMATISMS. 273 

gaping of the surfaces, the wound is dusted with iodoform, and 
is not disturbed for four days. 

Martin, in extensive relaxation of the pelvic floor, supple- 
ments the operation upon the vulvar outlet by a denudation of 
the lateral columns of the vagina, leaving a tongue-shaped, 
undenuded strip in the median line of the vagina. (Figs. 254 
and 257.) Each lateral denudation is obliterated by continuous 




^- ' 




^^ 



Fig. 260. — Introduction of Suture in Retracted Flap. — {Andrews.) 

suture, after which the outlet is closed with transverse sutures, 
(Fig. 257.) 

Bischoff dissects up a flap from the posterior vaginal wall, 
which he utilizes in covering over the line of vaginal union. 
The perineal sutures are passed deeply beneath the flap. (Fig. 
258.) 

In the incomplete lacerations with relaxation of the pelvic 
floor the aim of the operative procedure is to take up the slack 
in the vaginal wall and restore the support to the suprajacent 
18 



274 



GYNECOLOGY. 



viscera. Andrews, of Chicago, does this by first dissecting a 
small triangle pointed below by a line drawn across the vagina 
between the caruncul^ myrtiformes and below by the mnco- 
integumental border; second, at the outer angle of this triangle 
on each side, a finger is pushed beneath the mucous membrane 
to just beneath the cervix. This line is incised on each side, 
permitting the central flap to contract (Figs. 259, 260, 261); 
third, from the side of the cerAax a suture is introduced through 




^ 



Fig. 261. — Suture Tied 



the Remaining Surface to be closed by Transverse 
Sutures. — (Andrews.) 



the wall, carried as a submucous stitch around the central flap 
already designated, and tied. This folds the flap beneath and 
behind the cervix. This suture straightens or smooths out the 
posterior vaginal wall. The remaining portion is united by 
transverse sutures. Harris, of Chicago, seeks to utilize the 
pubo-perineal portion of the levator ani to hold the posterior 
segment of the vagina against the anterior by dissecting down 



TRAUMATISMS. 



275 



upon the muscle upon each side, excising a section, and uniting 
the cut surface. The fascia has been denuded over the posterior 
segment and sutures are at once inserted posterior to the re- 
tracted muscle. 

Flap Operations. 

Taifs operation is the representative for the various flap 
operations. In incomplete tears the rectum is tamponed with 





Fig. 262, — Outline of Flap to be Turned Down to Form Raw Surface for 
Union. Flap thus formed to protect from fecal infection. — {Restine.) 



a Sponge or with cotton or iodoform gauze covered with vaselin 
and furnished with a thread. While an assistant separates 
the vulva, two fingers are passed into the rectum, rendering 
the posterior wall tense. To form the flap, Tait uses pointed 
angular scissors. The point of one blade is inserted in the 
median line at the mucocutaneous junction, and the recto- 
vaginal septum is split to the depth of two centimeters, first 



276 



GYNECOLOGY. 



to the left and then to the right, and is carried forward upon 
each side to the point at which he wishes the posterior com- 
missure to be. (Figs. 264, 265, and 266.) This forms a semi- 
circle following the mucocutaneous junction. The flap is 
drawn up by tenacula and further separated to the required 
depth. On the borders the incision is carried deeply into the 
cellular tissue of the perineum and labium ma jus. Bleeding 




J, 



Fig. 263. — Flap Turned Down, Sphincter Closed and Sutures Introduced, 

— {Ristine.) 



is controlled by forceps, and later by the pressure of the sutures. 
The sutures are passed with the fingers in the rectum as a guide. 
They pass transversely across the wound, the skin not being 
included. Four sutures are generally sufficient. The sutures are 
secured after the wound has been washed with sublimate solution 
(i : 1000) and the tampon has been removed. 

Sanger closes the skin edges with superficial sutures. 



TRAUMATISMS. 



277 



In complete laceration the rectovaginal septum is split, form- 
ing a rectal and a vaginal flap, depending in extent upon the 
depth of the tear. Sanger advises that it be made with the 
bistoury. These flaps are loosened at either extremity by pro- 
longing the incision upward just within the labia, and down- 
ward alongside the anus, thus forming a letter H, the trans- 
verse bar of which is formed by the split in the septum, and 
is at the lower part of the letter. These flaps, when separated, 




Fig. 264. — Incision for Tait's Operation for Incomplete Laceration. 



form a quadrilateral. Great care must be exercised in the 
introduction of the first suture, which must include the ends 
of the sphincter ani. 

Ristine, of Knoxville, Tenn., in complete laceration of the 
perineum, begins in the vagina and dissects a flap downward 
to the rectovaginal margin of the tear. This flap is made 
sufficiently long to insure its projection beyond the anus. The 



278 



GYNECOLOGY. 



divided ends of the sphincter ani are exposed and united with 
silkworm-gut sutures. (Figs. 262 and 263.) The flap is fastened 
over the line of union and serves to protect it from infection. 
This flap can be clipped off at a later date after it has com- 
pletely served the purpose for which it was constructed. The 
same object is secured by Noble, of Atlanta, who loosens and 
draws down the anterior wall of the rectum. The tag of tissue 
thus formed subsequently contracts. 



/'W^ 






^ 



Fig. 265. — Line of Incision for Tait's 
Operation for Complete Lacera- 
tion. 



Fig. 266. — Appearance of Surface 
after Formation of Flaps. 



Simpson's method is somewhat similar to Tait's in the manner 
of forming the flaps, but they are sutured separately, form- 
ing the anterior wall of the rectum and the posterior wall of 
the vagina, while the intervening funnel-shaped raw surface 
is united by sutures. (Figs. 267 and 268.) 

Fritsch's procedure still more closely resembles Tait's in 
the splitting of the flaps. (Figs. 269 and 270.) He detaches 



TRAUMATISMS. 



279 



the rectum from the vagina, adds a lateral incision for the 
sphincter when its ends are retracted, and unites these with 
a provisional stitch, which serves during the operation to restore 
the shape of the orifice and to permit the accomplishment 
of reunion. He unites the rectum with catgut, using the Lauen- 
stein suture. The same suture is used to close the vagina, 





Fig. 267. — Outline for Simpson's Operation. 



and the perineum is completed by suture in superposed planes 
or by continuous catgut sutures in terraces. 

Alexander Duke, after introducing the left index-finger 
nearly its entire length into the rectum, with a double-edged 
bistoury penetrates the septum a distance of six centimeters; 
as the knife is withdrawn he enlarges the incision laterally 
to five centimeters. As the lateral ends of the incision are 



280 GYNECOLOGY. 

pressed toward, each other a lozenge-shaped opening appears. 
The sutures are introduced with a strong, sickle-shaped needle 
with eye in point, and silver wire is preferred for the suture. 
The needle is introduced just beyond the end of the incision, 
and, guided by the finger in the rectum, is made to encircle 
the incision, to be brought out beyond its opposite end. Draw- 
ing up this suture will give an idea of the number of additional 







/ 



/ 



Fig. 268. — Sutures Introduced in Simpson's Operation. 

sutures required. The sutures secured, the distance between 
the anus and the posterior commissure is considerably increased, 
with the formation of a thick perineal body. 

304. After-treatment. — Immediately after operation cleanse 
the vulva with alcohol and water, equal parts, dry and apply 
a sterile gauze pad which should be retained with a T-bandage. 
The nurse should be directed to sponge the parts with the same 



TRAUMATISMS. 



281 



solution, whenever soiled. The patient is unlikely to suffer 
pain, unless the laceration has been complete, when a suppository 
of opium extract, gr. j, and hyoscyamus extract, gr. |, can 
be employed. The urine should be evacuated spontaneously 
and the parts subsequently sponged, as already advised. The 
position of the patient may be changed, but she should be 
discouraged from making severe efforts. In incomplete lacera- 
tions the diet will not require careful scrutiny, but in the com- 




Fig. 269. — Denudation for Fritsch's Operation. 



plete it should be limited during the first week to animal broths, 
and subsequently for another week it should be restricted to 
articles that are easily digested. Secure an evacuation of the 
bowels upon the third day, and at least each alternate day 
subsequently. Exercise care that excessive purgation shall 
not occur. The sutures, if of silk or silkrv^orm-gut, can be 
removed in from eight days to two weeks. Catgut sutures 
need not be disturbed. Observe care in the removal of the 



282 



GYNECOLOGY. 



sutures; the patient is preferably placed upon her side before 
a good light, and an assistant gently separates the buttocks, 
exposes the ends of the sutures and facilitates their withdrawal. 
Keep the patient in bed fully three weeks. After the fourth 
day the vagina may be irrigated once or twice daily with a 
disinfectant solution — sublimate (i : 2000) or formalin (i : 1500). 
Advise her to do but little walking for a month, and interdict 
coition for two months. 





Fig. 270. — Catgut Sutures for Union of 
the Rectal Wall. 



Fig. 271. — Incision for Duke's Op- 
eration. 



305. Choice of Operation. — It should be understood that 
no operation is applicable to every patient. The operation 
should be adapted to the special condition. In incomplete 
tears, without rectocele, the Simon-Hegar operation is satis- 
factory. In patients with rectocele, Emmet's or Dudley's 
operation will serve an excellent purpose. In cases of complete 
laceration, without much relaxation of the pelvic floor, no 



INFLAMMATIONS. 



283 



procedure presents so many advantages as that described by 
Tait and modified by Sanger. If the tissues are redundant 




Fig. 272. — Incision Separated in 
Vertical Direction. 



Fig. 273. — Incision United by Trans- 
verse Sutures. 



and there is need to afford support, the operation of Emmet 
for complete laceration is the most acceptable. 



INFLAMMATIONS. 

306. The recognition of the development of the genital tract 

from the coalescence of the ^lullerian ducts makes it evident 
that it is a continuous canal which must be especially vulnerable 
to infection and the manifestations of its results in an inflamma- 
tion. In experience it is rarely found that the alterations due 
to infection are confined to a single portion of this tract. It 
must be admitted, however, that the special structure of certain 
portions of the canal renders it more susceptible to the influence 
of special micro-organisms and their products. The cylindric 
epithelium of the cervical canal is more vulnerable to gonorrheal 
infection than is the pavement epithelium lining the vagina. 
The recognition of the almost continuous uniformity with which 
the dift'erent parts of the canal become involved from the struc- 
ture primarily infected, and the frequent difficulty in isolating 
the primary site, have caused me to depart from the usual order 
in the consideration of this subject, and to discuss infection 
and the resulting inflammation as affecting the entire genito- 



284 GYNECOLOGY. 

urinary tract, and subsequently to consider the features of its 
local manifestations. 

307. Micro-organisms as a Cause. — The most important ex- 
citing cause in the production of inflammation of the genito- 
urinary tract is the influence of micro-organisms. Inoculation of 
a mucous surface with a micro-organism may result in an imme- 
diate inflammatory reaction, which may subsequently extend to 
the neighboring structures by one of three ways: the mucous 
membrane, the lymphatics, or the blood-vessels. The original 
site of inoculation may be the vulva, vagina, uterus, or urethra, 
or the bladder surfaces, which are more or less exposed to external 
contact, or even 'the entire tract may be involved. 

308. Natural Protection against Infection. — The situation of 
the genital tract, the injuries to which it is exposed, and the 
opportunities for its infection by various germs render the com- 
paratively infrequent occurrence of inflammatory attacks sur- 
prising. The immunity against infection is to some degree 
secured by the difference in the character of the uterine and 
vaginal secretions. It will be remembered that the uterine 
secretion is alkaline, while that of the vagina is acid; conse- 
quently micro-organisms which would readily flourish in the one 
canal are unfitted for the invasion of the other. 

309. How Immunity is Lost. — Any condition, then, which 
causes these secretions to be less antagonistic, or which leads 
the one to greatly preponderate, permits the activity of the 
germs and their products to become manifest. Lowered vitality, 
exposure to cold, menstruation, the increased flow after par- 
turition, or abortion, all render the secretion more alkaline and 
establish a more uniform soil for the development of micro- 
organisms. Apparently normal conditions may be overcome at 
once when the tract has been inoculated with some virulent 
poison. 

310. Inflammation and its Varieties. — Inflammation has been 
defined as an expression of the effort made by a given organism 
to rid itself of, or to render inert, noxious irritants arising from 
within or introduced from without. Inflammation may be acute 
or chronic, diffuse or circumscribed. It is denominated as acute 
when associated with pain, heat, burning, more or less swelling 
of the tissues, profuse discharge, and constitutional symptoms. 
Inflammation is chronic when the condition is somewhat pro- 
tracted ; the pain less severe or but slight ; the discharge less in 
amount and less irritating to the surrounding structure, and with 
but slight constitutional reaction. Diffuse inflammation may 
involve the entire genital tract, as in streptococcic or gonococcic 
infection, either of which may extend the entire length of the 
genital canal, involving vulva, vagina, uterus, and tubes, and 



INFLAMMATIONS. 285 

even the ovaries, peritoneum, and cellular tissue. The latter 
form of infection may simultaneously invade the urinary tract, 
but circumscribed or local irritation confined to a portion of the 
tract is much more common. 

311. The causes of inflammation should be divided into pre- 
disposing and exciting. The predisposing causes are those which 
produce congestion and disturbance of the normal equilibrium of 
the tract and, consequently, promote a favorable condition for 
the inception of infection. They may arise from disturbance 
of menstruation, and involution, and from traumatism. The 
first includes the improper hygiene of menstruation, exposure to 
cold, fatigue, overexercise, and excessive sexual relation during 
the congestion immediately preceding or following menstruation. 
Not infrequently persons, to avoid the inconvenience of men- 
struation, will take a cold bath, with a view to its arrest. A 
prolific cause is neglect or imprudence following an abortion, 
miscarriage, or parturition. The natural congestion consequent 
upon these periods is enhanced by exposure, which permits 
infection by various micro-organisms, with the resultant inter- 
ference of the normal physiologic results in inflammation and 
interference with the normal processes and the subsequent 
development of inflammatory changes. Uncleanliness or want of 
care upon the part of physician or nurse in a manipulation 
during or following labor or an abortion, or in the use of the 
uterine or vaginal douche; upon the part of the patient in 
handling the parts with unclean hands ; the act of masturbation 
or the employment of unclean instruments ; the retention within 
the uterus or vagina of portions of placenta, decidua or blood- 
clots following abortion or labor; the presence of foreign bodies, 
such as tampons, tents, stem pessaries, and especially soft- 
rubber pessaries, w^hich are very prone to become foul, can 
properly be considered as causes. Traumatisms, including 
lacerations of the perineum, vagina, and cervix, from the un- 
skilful management of abortion or parturition, rough or unskilful 
examination, careless use of the sound or intrauterine manipula- 
tion, without asepsis, and excessive or violent coition, are also 
contributing factors. Chemic and vegetable poisons, such as 
phosphorus and the essential oils, may cause acute metritis. A 
patient suffering with chronic inflammation may have acute 
attacks which are excited by overexertion, sexual excess, opera- 
tions, or rough examinations. Inflammation may be promoted 
by the presence of uterine displacements, pelvic or uterine 
tumors, or profuse inflammatory exudates or morbid processes. 
The exciting causes are the pathogenic micro-organisms and 
their products. They are the gonococcus, the streptococcus 
pyogenes, the staphylococcus pyogenes aureus and albus, the 



286 GYNECOLOGY. 

bacillus coli communis, the bacillus tuberculosis, and the sapro- 
phytes from the bladder, rectum, and colon. 

Inflammation of the vulva and vagina can be produced 
by the passage through them of a septic discharge from a slough- 
ing fibroid, by malignant disease of the cervix or uterine body, 
by the contents of a pelvic abscess or pus-tube, or by the con- 
tact of feces or urine through fistulse. 

Of the various exciting causes named, the most prolific is 
gonorrhea. In woman gonorrhea is far more dangerous than 
syphilis, for when infection once occurs, the entire genito- 
urinary tract may become involved, and the individual sub- 
sequently suffers from chronic inflammation of the uterus, sup- 
puration of the tubes, inflammation of the peritoneum and 
ovaries, as well as cystitis, ureteritis, and inflammation of the 
pelves of the kidneys. She not only loses through its influence 
her power of reproduction, but develops inflammatory con- 
ditions which, if they do not cause a fatal termination, pro- 
duce such destructive changes in the pelvic organs as to neces- 
sitate their removal in order to prolong life or render it endur- 
able. When gonorrhea has not established sterility, its ex- 
istence, however, affords a favorable soil for the development 
of sepsis subsequent to abortion, parturition, or rough and 
unskilful manipulation. Careless examination, the introduc- 
tion of the sound, and other intra -uterine manipulation with- 
out thorough asepsis are too frequently the causes of extension 
of serious pelvic inflammation. 

Acute exacerbations are readily produced by overexertion, 
fatigue, cold, or rough manipulation when the pelvic organs 
are the seat of chronic inflammation. 

312. Characteristics of Inflammation. — It should be well 
understood that inflammation, in the great majority of cases, 
is primarily a product of infection, and, consequently, is not 
necessarily to be regarded as a reprehensible process, but, on 
the contrary, as an effort to guard and preserve the structures 
from injury and invasion. Its first aim, then, is defensive; 
the second, constructive and reparative. These processes are 
often so intermingled as to render differentiation difficult. 

The defensive element is more marked in the acute process, 
and is associated with proliferation, degeneration, and de- 
struction, dependent in degree upon the virulence of the in- 
fection and the capabilities of resistance. Efforts are made 
to establish a retaining wall. Blood stasis, cell proliferation, 
and exudation occur; degeneration and destruction follow. 
Such a process causes pain, a burning sensation, elevation of 
temperature, extreme sensitiveness, swelling, and more or 
less constitutional reaction. The process may terminate in 
resolution or go on to suppuration. 



INFLAMMATIONS. 287 

Acute and chronic inflammation are ofttimes mere stages 
in the infective process, and the one insensibly fades into the 
other. In the latter, defensive action is slight and not marked 
by an extensive limiting wall. Naturally, the symptoms are 
less severe, and, as the constructive elements predominate, 
as seen in hyperplastic conditions, the neuropathic disturbances 
are more marked. 

The inflammatory process may begin with a chill, or with 
repeated rigors, associated with elevation of temperature, and 
with tenderness over the pelvic organs, often so great as to 
render the contact of the clothing or bed-clothes quite unen- 
durable, especially when the peritoneum has become involved. 
Increased secretion and discharge is an invariable symptom, 
necessarily dependent upon the seat and character of the in- 
flammation. Disturbance of the functions of the genital organs 
also necessarily occurs. In acute attacks the organs are so 
sensitive that a digital examination is frequently attended 
with agonizing pain. 

The menses may be arrested (amenorrhea) or be greatly 
aggravated (menorrhagia), while not infrequently there is 
profuse irregular bleeding (metrorrhagia). Increased or ir- 
regular flow is more likely to be associated with involvement 
of the peritoneum and cellular tissues, because the resulting 
exudate obstructs the pelvic venous circulation. The bleeding 
occasionally is internal. More frequently, however, there is a 
transudation of serum and plasma into the cellular tissues, which 
forms the condition known as parametritis or pelvic cellulitis. 

313. Classification of Inflammation.— Frequently inflam- 
mation will begin in one portion and rapidly involve the struc- 
tures of the entire genito-urinary tract; therefore, it is difficult 
to specify any particular organ as its primary site. Further- 
more, in other cases the virulence of the micro-organisms may 
be so great and the defensive power of the patient so slight 
that general infection takes place, and localization, if it occurs, 
may be in organs remote from the site of original infection. 
The gonococcus is an example of the former, while infection 
with the streptococcus illustrates the latter. In the majority 
of cases inflammation preponderates in a portion of the genital 
canal or pelvic structure, and is named for the part mostly 
affected. 

Inflammation of the vulva, vulvitis. 

" ducts and glands of Bartholin, Bartholinitis. 

urethra, urethritis. 

" bladder, cystitis. 

vagina, vaginitis. 

uterus, metritis. 

" tubes, salpingitis. 

" ovaries, ovaritis or oophoritis 



288 GYNECOLOGY. 

A still more minute classification of inflammation is made 
in relation to the particular structure or portion of the organ 
involved, as, the mucous membrane, the muscular structure, 
or the periphery. Thus, with the vagina we may have an 
endo vaginitis, a parenchymatous vaginitis, and a peripheral 
or perivaginitis. The uterus furnishes an endometritis, a 
parenchymatous metritis, a perimetritis, the latter involving 
the peritoneal covering, and an inflammation of the cellular 
tissue, known as parametritis or, better, pelvic cellulitis. The 
tube is affected by endosalpingitis, parenchymatous salpingitis, 
and perisalpingitis. Inflammation of the serous covering of 
the uterus, as announced, is called perimetritis. It is, however, 
rare to find this portion of the peritoneum alone involved. 
More frequently, the entire pelvic peritoneum, including that 
of the uterus, broad ligaments, and tubes, is inflamed, so that 
the term pelvic peritonitis affords a more accurate description. 
Inflamm.ation of the pelvic peritoneum rarely occurs without 
more or less inflammation of the cellular tissue. It can not 
be denied that we may have cellular inflammation without 
very extensive involvement of the enveloping peritoneum. 
When this occurs, it is known as pelvic cellulitis. 

314. Vulvitis and its Varieties. — Inflammation of the vulva 
varies in degree from a slight erythema to a very severe and 
destructive involvement which may result in the formation 
of an extensive abscess, or in the destruction of a large portion 
of the labium. It is usually divided into simple or catarrhal, 
follicular, venereal, eruptive, phlegmonous, and diphtheritic. 

315. Causes. — Vulvitis is generally produced by infection. 
Its development is favored by neglect of cleanliness. The 
accumulation of secretion from the sebaceous and sudoriferous 
glands; the decomposition of the smegma, which accumulates 
between the labia majora and labia minora and beneath the 
prepuce of the clitoris, will often cause an attack of inflammation 
similar to balanitis in the uncleanly male. In obese women 
the decomposing perspiration, frequently associated with vaginal 
discharges, will keep the surfaces constantly irritated. 

The tendency to the condition is enhanced by the gouty, 
rheumatic, and scrofulous diathesis, and by intemperance in 
eating and drinking, especially the latter. Vulvitis is often 
produced by uterine and vaginal discharge, from malignant 
disease or from discharging abscesses. 

The continual soiling of the vulva with the urinary and 
fecal discharge as a result of fistulae is productive of vulvar 
inflammation and often erosion of the surfaces. Vulvitis 
is excited and aggravated by masturbation, and excessive 
coition, from the pruritus occasioned by the presence of pin- 



INFLAMMATIONS. 289 

worms, ants, and pediculi. The various eruptive diseases, 
as eczema, herpes, acne, furuncle, warts, and venereal sores, 
are productive causes. A severe form of vulvitis is generally 
associated with eczema, and intense pruritus is caused by 
the presence of the torulae cerevisiag in diabetic urine. Inspec- 
tion will reveal whitish tufts over the surface, which arise from 
the spores of the oidium albicans. Severe vulvitis with eczema 
should always lead to examination of the urine in order to 
exclude the presence of sugar. Vulvitis is a frequent complica- 
tion in the eruptive and infectious diseases of childhood, such 
as scarlatina and diphtheria. It may arise from the extension 
of inflammation from the anus or bladder. 

316. Vulvitis — Simple or Catarrhal. — In the acute stage 
of vulvitis the labia minora, the clitoris, and the fourchet are 
swollen and thickened. The parts are red, angry, and dry; 
later, they are covered with a profuse purulent discharge of 
an extremely offensive odor. This discharge is produced by 
an increased secretion of the sebaceous glands mixed with 
desquamated epithelium and pus-corpuscles. 

Pruritus, as in all forms of vulvar inflammation, is a marked 
symptom, and is at times so severe as to prevent sleeping and 
force the patient to abjure society. The temptation to scratch 
or rub the parts becomes almost irresistible. The contact 
of the urine causes smarting or burning. As the disease be- 
comes chronic, the surface is not so bright a red; it becomes 
abraded; at points, small ulcers form, the skin is greatly thick- 
ened, the papillae become hypertrophied, bleed easily, and are 
red; often the surface presents points of excoriation, which 
extend upon the vulva into the groins and the inside of the 
thighs, when the itching is intolerable. The glands in the 
groin often become swollen, and may even undergo suppuration. 

317. Follicular Vulvitis. — The follicular inflammation is 
limited to the hair follicles or originates in the sudoriferous 
and sebaceous glands. The surface of the vulva is studded 
with small round protuberances the size of a millet-seed or 
hemp-seed. These elevations begin as papules, which may 
suppurate, forming pustules, which burst and shrivel, or they 
may remain as small indurations. The intervening skin is 
unaffected. 

318. Venereal Vulvitis. — Venereal inflammation of the vulva 
is produced by gonorrhea, syphilis, and chancroid. The former 
is the most prolific source. Gonorrheal vulvitis is much more 
intense than the catarrhal. It particularly involves the ves- 
tibule and smaller labia. The latter are very red and ede- 
matous, while the external meatus of the urethra and the ori- 
fices of the ducts of Bartholin are generally red and swollen. 

19 



290 



GYNECOLOGY. 



Small excoriations frequently occur which bleed easily. The 
disease is attended with a very profuse purulent secretion, in 
which the gonococcus is found. The microscope shows the 
subepithelial tissue exceedingly vascular and infiltrated with 
solid groups of round cells. The epithelium will be seen in 
varying stages of granular degeneration and desquamation. 
Gonococci penetrate the epithelium and are found in the under- 
lying tissues. The inflammation extends to the vagina, not 




Fig. 274. — Follicular Vulvitis. 



infrequently through the urethra to the bladder, and often 
Bartholin's glands are inflamed, occasionally resulting in abscess 
formation. Micturition is followed by intense burning. Vul- 
vitis due to syphilis occurs in the form of a single sore with 
indurated base and excavated surface, which is situated upon 
the large or small labium or in the neighborhood of the clitoris. 
In the secondary stage there are mucous patches similar to 



INFLAMMATIONS. 291 

those found in the mouth. Chancroids produce a more or 
less extensive ulceration, generally involving adjoining sur- 
faces; syphilis causes indurated enlargement of the inguinal 
lymphatic glands, while chancroid is characterized by their 
inflammation and suppuration, causing the formation of buboes. 

319. Eruptive Diseases of the Vulva. — Skin diseases mani- 
fest the same characteristics when situated upon the vulva 
as in other portions of the body. The most important, be- 
cause the most frequent, are eczema, erysipelas, and herpes. 

Eczema generally begins upon the labium ma jus or upon 
the mons veneris, from which it extends to the thighs, peri- 
neum, anus, and over the buttocks. In the acute stage the 
surface becomes red and swollen, burns, and is covered with 
transparent vesicles the size of a pinhead. It is associated 
with fever, gastric irritation, and rheumatic symptoms, and 
becomes chronic by the end of the second week. Chronic 
eczema generally appears in the form of eczema rubrum and 
the surface is covered with pus, dry scales, or crusts. Fissures 
form at the fourchet and anus and in the genitocrural folds. 
All the symptoms are greatly aggravated at the menstrual 
periods. Pruritus is intolerable. The occurrence of eczema 
of the vulva is generally associated with the appearance of 
the disease upon other parts of the body. It is a frequent 
consequence of diabetes mellitus, owing to the irritation of 
the sugar-containing urine. It is also an outcome of the rheu- 
matic diathesis. 

Erysipelas may occur as a primary affection of the vulva 
in the new-born, when it is a very serious disease, frequently 
proving fatal. It occasionally occurs periodically with the 
catamenia, or may even take the place of the latter. Its oc- 
currence during the puerperal state is generally an indication 
of serious infection. 

Herpes manifests itself by the appearance of small trans- 
parent vesicles, from the size of a pinhead to that of a pea, 
which may be few or multiple, discrete or confluent; rarely, 
as a single erosion of large extent. The advent of the disease 
is characterized by heat, smarting, and an area of redness, 
which is covered with agminated vesicles. These vesicles 
may fuse, and form a large bulla. The vesicles dry; the edges 
of an ulcer are scalloped and its surface is covered with a crust, 
beneath which cicatrization is completed within from eight 
to fifteen days. The inguinal glands are engorged and pain- 
ful, but do not suppurate. 

Causes. — Accident,al herpes is caused by syphilis, gonorrhea, 
filth, and constitutional conditions. Congestion is a predis- 



292 GYNECOLOGY. 

posing cause. In some it occurs each month two days in ad- 
vance of menstruation; also during pregnancy. 

320. Phlegmonous Vulvitis. — Phlegmonous inflammation of 
the tissues may result from the catarrhal or may be the result 
of violence. It affects the deeper structures and subcutaneous 
tissues, resulting in serpiginous ulceration, which forms a per- 
manent fistulous tract, or may terminate in the formation of 
an abscess. 

321. Diphtheric Vulvitis. — Diphtheria may, but rarely does, 
affect the vulvar mucous membrane. The so-called diphtheric 
vulvitis is an exudation found upon lesions of the vulva and 
vagina, produced by parturition, and is the result of septic infec- 
tion. Such exudations are also found in grave constitutional 
disorders, such as scarlatina, smallpox, and typhoid fever. 

In a woman who succumbed to sepsis subsequent to the 
delivery of an intra -uterine sessile fibroid whom I saw prior 
to death, the vulva, vagina, and uterus were lined with a diph- 
theric exudate. 

322. Diagnosis of Inflammatory Disease of the Vulva. — 
The diagnosis, especially the differential diagnosis, of the inflam- 
matory disorders of the vulva is of great practical importance. 
Gonorrheal vulvitis is evident from the greater intensity of its 
symptoms. It is characterized by an increased burning dur- 
ing micturition, profuse purulent discharge, and redness of the 
meatus and orifices of the ducts of Bartholin. It has a tendency 
to extend to the tubes, ovaries, and peritoneum, as well as an in- 
creased inclination to involve the urinary tract. Its recognition 
is rendered certain by the discovery of the gonococcus, and the 
known fact of exposure to the virus. The absence of the gono- 
coccus is not proof positive against the specific character of the 
disease, as the germ may have disappeared. (For method of dis- 
covering the gonococcus see Section 90.) 

The production of vulvitis in the virgin by masturbation is 
suspected when the smaller labia and the space between them 
and the hymen are covered with small, pointed excrescences ; the 
nymphas are elongated; the clitoris or its prepuce is irritated; 
swelling of the shallow groove between the orifice of the urethra 
and the clitoris exists ; clear, abundant secretion from the ducts 
of Bartholin occurs ; and associated with these phenomena there 
is abnormal sensibility ; exaggerated prudery ; and distinct hysteric 
symptoms. Discontinuance of masturbation may be assumed 
when the hypertrophied nymphag become soft and no longer 
show any indication of inflammation. 

Eczema can be recognized by the similarity of its symptoms 
to those of the disease when it occurs in other portions of the 
body. Finding the cervix covered with whitish tufts should 



INFLAMMATIONS. 293 

arouse suspicion of the presence of torula cerevisias, which is 
confirmed by the microscope and the discovery of sugar in the 
urine. It is a good plan to carefully examine the urine in every 
case of eczema of the vulva. Herpes is frequently confounded 
with chancroid, from which it is distinguished by its early his- 
tory. The formation of a vesicle is followed by its rupture, 
leaving a raw surface without a thickened inflammatory base 
and without loss of substance. The burning is more acute and 
the inflammatory symptoms subside more quickly. The lymph- 
atic glands of the groin may become inflamed, but do not 
suppurate. The duration of herpes is from eight to fifteen days. 
In chancroid the sore has an uneven, fissured base, the edges 
of which are sharply defined, and its surface is covered with a 
greenish discharge. It presents points of abrasion, and generally 
the apposed surface becomes inoculated. Bubo develops in the 
groin. 

323. Treatment. — In all forms of vulvitis absolute cleanliness 
is essential. In the simple acute variety, absolute rest and the 
administration of salines are indicated. Tincture of aconite can 
be given in drop doses every one or two hours to decrease inflam- 
mation. In all varieties thorough local cleanliness must be 
observed. In the simple and follicular forms cleansing and 
isolation of the inflamed parts will frequently be sufficient to 
establish a cure. The cause of the inflammation, if possible, 
should be determined, and, when practicable, remedial measures 
should be directed to its removal. Vaginal discharge should be 
arrested, and the inflamed surfaces should be protected from its 
contact. The rheumatic, gouty, and scrofulous diatheses and 
improper habits must be corrected by proper hygienic and con- 
stitutional measures. The food should be carefully regulated 
and all stimulating and indigestible articles avoided. Alcohol 
in any form should be interdicted, excepting in the diphtheric 
and phlegmonous varieties. In the acute stages a bland diet or 
exclusive milk diet may be advisable. 

Catarrhal and Gonorrheal Vulvitis. — The treatment of these 
forms is of great importance, as infection may lurk in the dis- 
eased tissues for years. Cleanliness is secured by the employment 
of the hot sitz bath several times daily, by antiseptic fomenta- 
tions, such as gauze pads moistened with sublimate solution, 
I : 2000 or I :iooo; carbolic acid, i :2o; boracic acid solution, 
I : 50, or a 5 per cent, solution of antipyrin, placed over the 
vulva and covered with oil silk or rubber dam. In very acute 
conditions the distress will be much more quickly ameliorated by 
the application of lead-water and laudanum. This application 
may be kept cold by an ice-bag placed over it. These appli- 
cations, whether antiseptic or emollient, should be frequently 



294 GYNECOLOGY. 

changed, the parts protected from vaginal discharge by a tampon, 
and the inflamed surfaces painted several times daily with a 
solution of Monsell's salt, i to 8, in glycerin; on each alternate 
day silver nitrate, gr. x to the fluidounce, or compound tincture 
of iodin in water, i to 2, should be used. "Protargol, largin, 
argyrol, and argonin have been especially advocated as valuable 
in the gonorrheal form; alumnol in 2 per cent, solution has also 
been advocated. Ramon Guiteras highly recommends mercurol 
in 2 per cent, solution. These agents are more effective in the 
gonorrheal form. The sides of the vulva should be separated 
with absorbent cotton, surgeon's lint, or prepared cotton. After 
the subsidence of the more acute stage, the surfaces should be 
dusted with zinc oxid, bismuth subnitrate, iodoform, lycopodium, 
starch, talcum, or one of the various combinations of these 
powders. Iodoform and tannin in equal parts are very efficient. 
Equal parts of alum and sugar afford relief in pruritus. Buboes 
and abscesses should be promptly incised and their cavities 
sterilized. In chronic vulvitis, astringents or caustics may be 
employed, the latter with the purpose of promoting sufficient 
metabolism to take up inflammatory exudate which has led to 
thickening of the tissues. Benzoated zinc ointment is a soothing 
application. The surfaces may be dusted with calomel or bis- 
muth subgallate. Gonorrheal vulvitis is usually secondary. In 
chancroid, the parts should be kept clean by frequent washing, 
the inflamed area isolated by gauze or lint, and drying . powders 
should be employed, such as iodoform, iodoform and tannic 
acid in equal parts, aristol and desiccated alum, 4 to i, calomel 
and zinc oxid and bismuth subgallate. In herpes, keep the 
surfaces clean and separated. Drying powders should be em- 
ployed. 

In follicular vulvitis, in addition to strong antiseptics, alkaline 
solutions are efficient. It may be necessary to shave the parts 
and to puncture and cauterize the individual follicles, or, in rare 
cases, to excise the affected surface. The ointment of ammoni- 
ated mercury, diachylon ointment, or ichthyol in lanolin (J- 1 :4) 
may be useful. Phlegmonous and diphtheric vulvitis require 
cleanliness, antiseptics, removal of sloughing tissue, and, in the 
latter, cauterization of the infected surfaces with strong carbolic 
acid. 

Eczema, when acute, must be treated with emollient appli- 
cations or starch poultices, and the surfaces should be carefully 
cleansed. The bowels should be regulated and constitutional 
measures employed for the correction of any disordered condi- 
tion. When eczema is associated with diabetes, compresses of 
hyposulphite of soda, half an ounce to the pint, should be kept 
in contact with the inflamed surfaces. In chronic eczema, the 



INFLAMMATIONS. 295 

parts should be thoroughly Avashed with strong potash soap and 
hot water. By this measure all crusts and scales are removed. 
Where the surfaces are too much irritated, cracked, and fissured 
for this plan of treatment, a starch or slippery elm poultice may 
be applied. After thoroughly cleansing the surfaces, the applica- 
tion of the following ointments will prove of value : 

K: . Hydrarg. ammoniat., ^ ss 

Lanolin, ^ij. M. 

Ft. ungt. 

li . Iodoform, 5 j 

Zinc, oxid, ^ij 

Lanolin, Jiij- M. 

Ft. ungt. 

Or diachylon ointment or one of the tar preparations may be 
employed. If the irritation is apparently kept up by a vaginal 
discharge, use a vaginal tampon. Laxatives should be given to 
regulate the bowels, and constitutional measures should be em- 
ployed for the correction of arthritic, scrofulous, or diabetic con- 
ditions, from any one of which the disease may have originated. 

324. Edema and Gangrene. — Edema of the vulva is fre- 
quently associated w4th pregnancy. It is common in ascites 
as a result of various obstructions of the circulation. It may 
follow labor and also result from varix of the external pudic 
vein. When one side of the vulva only is involved, infection 
should be suspected. Incisions of the vulva or spontaneous 
fissures permit the fluid to escape, but increase the danger 
of erysipelas, and may be followed by gangrene and slough- 
ing of the labia. The swelling in general anasarca is very 
great, and may render urination or the use of the catheter 
very difficult. 

A hard edema of one labium can occur from and persist 
after chancre. When it appears in the nymphae or prseputii 
clitoridis, it resembles elephantiasis. The condition is known 
as syphilitic hypertrophy of the vulva. 

Gangrene of the vulva may be produced by traumatism, 
septicemia, and occur in weak and scrofulous infants. This 
form of gangrene in young children is known as noma. It 
is infectious, and presents a reddened, infiltrated labium, and 
an ichorous discharge. A vesicle appears, which rapidly be- 
comes gangrenous. 

The treatment of edema is the same as that of the condition 
from which it arises. That of gangrene or noma consists in 
early excision, disinfection, and the exercise of measures to 
secure effectual nourishment. 

325. Bartholinitis {Inflammation of the Glands of Bartholin). 
— These glands — also known as the vulvovaginal, Duverney's 



296 



GYNECOLOGY. 



and Cowper's glands — are racemose glands the size of a bean, 
situated in the labia majora at the junction of the posterior 
and middle thirds. The duct, two centimeters in length, opens 
in front of the hymen, with an orifice the size of a pinhead. 
Catarrh of these glands is rare, but hypersecretion is not in- 
frequent. It is indicated by redness about the opening of 
the duct, which may be either dilated or closed; in the latter 
case forming a retention cyst. The secretion from these glands 
may be thrown off in paroxysms, not infrequently in nocturnal 
emission. The secretion is particularly discharged during 
erotic excitement. 

Inflammation can occur in either the gland or the duct. 

It is generally due to specific infec- 
tion, but may arise from strepto- 
coccic or staphylococcic formes. In 
very severe cases it is apt to be a 
mixed infection. It is most gener- 
ally due, however, to gonorrhea. 
Gonorrheal inflammation having 
been lighted up in the gland, it 
may subsequently remain dormant, 
and afford material which may not 
only again infect the patient, but 
others coming in contact with the 
secretion. Inflammation, according 
to its virulence, may either produce 
a cyst or result in the development 
of an abscess. Cysts are either sin- 
gle or multilocular, ovoid, with a 
smooth surface, and seldom trans- 
parent; the contents are viscid and 
are colorless or yellow. From mix- 
ture with blood they may become 
chocolate colored. The cyst varies 
in size from that of a nut to that 
of an egg, is generally unilateral, 
and is most frequently situated on the left side, elongated in 
the axis of the greater lip, and nearer the mucous surface. It 
seems elastic and compressible rather than fluctuating; gives 
rise to discomfort in walking and during coition, and can be- 
come inflamed and suppurate. Superficial cysts, involving the 
duct, may attain to the size of a nut ; they are usually situated 
at the base of the labium minus, and may project into the 
vagina beneath the mucous membrane. A cyst of the gland is 
deep, is generally larger, and is located behind the labium majus ; 
it elevates both labia and its duct is impermeable. 




Fig. 275. 



-C3^st of Bartholin's 
Gland. 



INFLAMMATIONS. 297 

The diagnosis is readily determined. In either solid or 
fluid tumors fluctuation is absent, and the transparency is 
insufficient. But when the diagnosis is doubtful, it can be 
ascertained by puncture. The conditions with which it may 
be confounded are: first, sacculated cysts of old hernial sacs; 
second, hydroceles in the canal of Nuck; third, a cyst in front 
of a hernia. From hernia, which may be an epiplocele, an 
enterocele, or ovarian, it is distinguished by the absence of 
succussion in coughing, and by the determination of the con- 
nection of the mass with the abdomen. Hydrocele may fre- 
quently be displaced by pressure, is a larger tumor, gives more 
sensation of fluctuation, and is more translucent. Abscess 
may be secondary to the cyst or may originate from primary 
inflammation. Swelling and edema are marked over the pos- 
terior part of the vulva and about the anus, and the pain is 
acute and lancinating. The patient may have more or less 
fever; frequently, the urine is retained; fluctuation is distinct, 
and, if the abscess is not opened early, its contents may escape 
through several openings; pus is abundant and fetid. Fistulas 
may persist, and may result in a recto vulvar fistula, or a large 
ulcer may be present, associated with purulent secretion, or a 
hypertrophic induration of the gland, with profuse discharge 
of milky, greenish pus. The gland is the last refuge of gonorrheal 
inflammation and is a frequent source of unsuspected infection 
for men. It may be confused with fecal abscess, phlegmon 
of the labium majus, or furuncles. In fecal abscess there is 
more rectal disturbance, a more widely diffused inflammation, 
and the mass does not encroach to the same degree upon the 
labium. In phlegmon of the labium majus the inflammation 
is more external, and encroaches upon the cutaneous rather 
than upon the mucous surface. Furuncles are more sharply 
deflned and present an indurated base. 

Treatment. — In early inflammation of the duct it may be 
injected with a one per cent, solution of silver nitrate after 
evacuation of the pus. The duct may be opened with a lac- 
rimal knife and a crayon of silver nitrate or a solution of zinc 
chlorid (i : 50) may be introduced. In cysts, when the con- 
tents are evacuated by puncture, they quickly reappear. Ob- 
literation of the cyst may be secured by injecting ten drops 
of a solution of zinc chlorid (i : 10) after the contents have been 
removed by aspiration, or the cyst may be incised and packed 
with iodoform gauze. A preferable procedure would be ex- 
tirpation. In order to overcome the difficulty of removing 
the cyst when collapsed, it maybe punctured, emptied, irrigated 
with hot water, and injected with melted paraffin, and the 
latter hardened with ice, after which the mass thus formed 



298 GYNECOLOGY. 

is easily dissected. In abscess early free incision at the junc- 
tion of the skin and mucous surface is important. To ex- 
tirpate the gland, wash the cavity with carbolic solution and 
pack with gauze. In fistula it may be wise to extirpate and 
to close the cavity with catgut sutures. 

326. Pruritus Vulvae. ^Pruritus is a symptom of all forms 
of inflammation of the vulva. It results from the presence 
of pediculi, pin-worms, eczema, trichiasis; from hemorrhoids, 
disease of the kidneys, ureters, bladder, and urethra; from 
the congestion of the pelvic organs and masturbation; and 
from acrid vaginal discharges. It is associated with preg- 
nancy, menstruation, the menopause, old age, the gouty diath- 
esis, and general nervousness. It is directly caused by lice, 
acrid discharges, and diabetes. In addition to the sources 
given, there is a form of pruritus in which the origin remains 
undetermined. This is designated as an idiopathic pruritus. 
It is, however, very questionable whether careful examination 
will not disclose a demonstrable cause of the disorder. Seelig- 
man, in an investigation of a large number of cases, found in 
all a diplococcus, which resembles the gonococcus in appear- 
ance, but differs from it in its process of growth, and besides 
it takes the Gram stain'. 

Symptoms. — Pruritus produces intense itching, and, as a 
result of the scratching induced, excoriations are present, and 
the hair is often worn off the mons veneris. The patient avoids 
company, becomes melancholy, has loss of appetite and sleep 
and increased sexual desire, masturbation is excited, and she 
may become insane. Itching is continuous or occurs only 
at intervals, it is increased by heat, and is much worse at night 
or following any exertion. The relation of masturbation to 
pruritus is not always readily determined. The habit produces 
certain abnormal alterations as a result of the irritation: 
changes in the endometrium, glandular hypertrophy, ovarian 
irritation, increase of secretion, irritation and manipulation 
of the vulva. A bad circle is engendered; irritation causes 
masturbation, and this aggravates the inflammation. There 
are cases, however, in which most careful examination fails 
to disclose inflammation of the vulva as a source of the intense 
pruritus. These conditions are known as idiopathic pruritus, 
and are supposed to be due to nerve irritation. Such cases 
do not properly belong under the term inflammation of the 
vulva, but they are so rare, and the symptoms are so prominently 
associated with vulvitis, that their consideration seems more 
appropriate here. 

Prognosis. — The relief of the condition depends entirely 
upon its cause. In some cases it is exceedingly obstinate. 



INFLAMMATIONS. 299 

The removal of the cause, as filth, pediculi, or pin-worms, 
results in the removal of the disorder. The prognosis in mas- 
turbating alterations is by no means favorable. It may be 
exceedingly difficult to overcome the evil habit. 

Treatment. — The first aim in the treatment should be to 
discover and remove the cause. Upon the recognition of ped- 
iculi, the parts should be shaved, and blue ointment should 
be applied. A strong sublimate solution, however, is the most 
effective agent. The surfaces should be painted with a solu- 
tion containing one grain of corrosive sublimate to the ounce 
each of alcohol and water. Unless the parts are shaved, this 
application must be repeatedly made, for it is necessary to 
destroy not only the lice which are present, but also the spores. 
If the pruritus arises from the action of the ascarides scabiei 
(the itch insect), sulphur ointment or thirty-five grains of 
betanaphthol in one ounce of vaselin are efficient applications. 
Of course, in the latter condition, the application must be 
made to the entire body. 

The methods of treatment of eczema and vulvitis have 
already been given. When it is evident that the pruritus 
has been produced by pin-worms, the parts should be kept 
clean and the patient given fluid extract of senna and spigelia 
in half-ounce doses; a rectal injection of infusion of quassia, 
two ounces to the pint ; half a grain of sublimate to eight ounces 
of water; an injection of lime-water or a suppository of hxe 
grains of santonin are also efficient measures. Hemorrhoids, 
glycosuria, and other causes should be recognized and treated. 
The diet is important. Alcohol and spiced food should be 
excluded. The use of coffee will often cause severe pruritus. 
Alilk is an excellent basis for the diet. The general health 
should be carefully considered. Tonics, such as arsenic and 
quinin, should be administered. AVhen the patient is unable 
to rest, sleep should be secured by the administration of bro- 
mid of potash, 5j--5ij daily, or tincture of cannabis indica, gtt. 
xx-gtt. XXV, thrice daily. When the measures just named 
are insufficient to secure sleep, sulphonal or trional should be 
given in preference to opium. Local vaginal injections of hot 
water; carbolized, sublimated, or borated cotton tampons; 
or fomentations of lead-water and laudanum can be employed, 
or a saturated solution of bromid of potash may be painted 
over the surface several times daily. Local applications of 
chloroform in glycerin (i:8), hydrocyanic acid, two or three 
drops to the ounce, or a one per cent, solution of cocain may 
be used. A solution of carbolic acid, or a strong solution of 
silver nitrate, followed by cold compresses, may be employed. 
Seeligman advocates the use of an ointment containing lo 



300 



GYNECOLOGY. 



per cent, of guaiacol in vaselin, and when this is not effective, 
it should be increased to 15 to 20 per cent. An ointment con- 
taining acetate of lead, chloral, camphor, or chloroform (a 
dram to the ounce), combined with vaselin or menthol, solid 
stick of nitrate of silver, or the galvanic current are advised. 
In very obstinate cases the affected skin may be excised. Tam- 
pons containing equal parts of sulphurous acid and boroglycerid 

sometimes afford relief. 
Tobacco smoking has 
given relief when all 
other means have 
failed. 

327. Kraurosis vul- 
vae is an obscure form 
of disease, first rec- 
ognized by Breisky, 
which consists of an 
atrophy of the smaller 
labia. The skin of the 
vulva undergoes essen- 
tial changes. The cap- 
illaries of the corium 
become dilated, the 
rete mucosum becomes 
thin and disappears, 
while there is a sub- 
stitution of a thick 
horny layer of epithe- 
lium, which lies directly 
upon the corium. The 
papillas disappear, the 
undulating character of 
the skin is lost, and it 
becomes stiff and scle- 
rosed, with here and 
there points of small 
cell infiltration. As the 
disease progresses the sebaceous and sweat-glands are entirely 
destroyed. It is called chronic inflammatory hyperplasia of the 
connective tissue with incHnation to cicatricial shrinking (Peter). 
Mars divides kraurosis into two stages: (i) The stage of 
edema, characterized by more or less inflammatory reaction; 
(2) the atrophy of elastic and connective-tissue skin layers 
with the formation of scar tissue, but Heller says it may be 
independent of the inflammatory process. He attributes it 
to some chemic irritation or a direct disease of the medullated 




Fig. 276. — Kraurosis Vulvas. 



INFLAMMATIONS. 301 

nerves, which leads to atrophy of the muscles, fat, and glands 
in the deeper layers of the skin, Avhile a hypertrophic process, 
especially a hyperkeratosis, occurs in the superficial layer. 

Causes. — The cause is unknown. It has been attributed to 
gonorrhea and pruritus. A preceding inflammatory stage exists 
(Martin). Breisky found it more frequently in the pregnant; 
Martin and others, in the nonpregnant. 

Symptoms. — The surfaces become contracted, presenting a 
smooth cicatricial appearance, devoid of glands, with reddened, 
inflamed points, not fully cicatrized. Pruritus is intense and 
there is severe burning and pain upon urination. The surface 
is dry, smooth, contracted, often flssured. The labia minora 
entirely disappear and the clitoris becomes a mere papule. 
The vulvar orifice is contracted, and causes coition to be ex- 
ceedingly painful, often impossible. Childbirth results in exten- 
sive laceration. 

Diagnosis. — The scratching of this disease should be sepa- 
rated from that of onanism and pruritus. The gratification 
induced by masturbation and the absence of cicatricial changes 
distinguish it. In pruritus the tears and superficial injuries 
are more marked and the disease is not so general, while in 
kraurosis the border of disease is more sharply defined toward 
the healthy skin. 

Prognosis. — Its spontaneous recovery is very doubtful. 
That carcinoma occasionally develops from it is exceedingly 
probable. 

Treatment. — The disease is exceedingly intractable to treat- 
ment. The application of cocain adds to the discomfort. Re- 
lief has been afforded by applications of strong carbolic acid, 
or of pledgets wet with a solution of lead acetate. The thermo- 
cautery has been applied. The most effective treatment is 
the excision of the affected tissue, accomplishing union of the 
healthy tissue by sutures. Care must be exercised to prevent 
narrowing of the urethra. 

328. Vaginismus is a term employed to represent an abnor- 
mal hyperesthesia of the external genital organs which pro- 
duces muscular spasm. It is common in young, nervous, or 
hysteric women, and occasionally occurs without our being 
able to discover any source of irritation. Generally, a care- 
ful examination will disclose an irritable spot in the fossa navi- 
cularis; an inflamed and thickened hymen, which has failed 
to rupture, or when it has ruptured, irritable carunculae myrti- 
formes; fissures in the fourchet or around the orifice of the 
vagina; small ulcerations within the hymen; fissure of the 
anus; urethral caruncle, or an irritable urethra. Nervous 
irritation of the vulva may be engendered by -association with 
an impotent or partly impotent man. 



302 GYNECOLOGY. 

Symptoms. — Dyspareunia, or painful coition, and sterility 
are the most marked symptoms. The slightest touch, or even 
the approach of the male, may cause powerful spasm of the 
sphincter vagina muscle. I have seen similar spasm occur 
at every attempt at urination in a very hysterical woman. 
The suffering is so intense as to lead the patient at once to 
seek medical advice, or through a sense of delicacy she may 
endure the distress until it becomes intolerable. She becomes 
careworn, anxious, and even hysteric. The ordinary vaginal 
examination is often extremely painful. I have, however, 
observed patients in whom the pain seemed confined to the 
attempts at coition, and they apparently experienced no un- 
usual discomfort during a careful pelvic investigation. Be- 
fore attempting digital examination it is well to carefully in- 
spect the surfaces, and to push the labia apart, when possibly 
the cause will be discovered. Hildebrandt has described a 
form of vaginismus due to spasm of the levator ani muscles, 
known as superior vaginismus, which is responsible for that 
unpleasant complication, penis captivus. It must not be over- 
looked that dyspareunia is occasioned by pathologic lesions 
of the floor of the pelvis, such as prolapsed, inflamed ovaries 
and tubes, inflammation of the cervix, pelvic cellulitis, or peri- 
tonitis. 

Prognosis as to cure is good. 

Treatment.— The first essential in treatment must be the 
removal of the cause. When the hymen is thickened and 
sensitive, it may be necessary to cut it completely away. Its 
mucous surfaces, however, should be sutured, in order to pre- 
clude the formation of cicatricial tissue. In irritable fissure 
the base should be divided, as in fissure of the anus, or touched 
with the thermocautery. Local applications are often effec- 
tive, of which one of the best is iodoform in powder or oint- 
ment. Its disagreeable odor, which often precludes its use, 
may be overcome by rubbing up a few drops of oil of eucalyptus 
with each ounce of the powder. Pledgets of cotton soaked 
in a four per cent, solution of chloral or in a two per cent, solu- 
tion of carbolic acid are useful. Ointments of opium, bella- 
donna, or ichthyol often afford relief. Neuromata, irritable 
carunculae myrtiformes, and urethral carunculae should be 
snipped off. In fissure of the neck of the bladder the urethra 
should be overstretched and cocain filaments or pencils should 
be used. In obstinate spasm glass dilators or plugs (see Fig. 
149) should be worn for an hour night and morning. The 
pain caused by the introduction of the plug soon ceases, and 
it can be decreased by anointing it with a medicated ointment. 
These instruments should gradually be increased in size. When 



INFLAMMATIONS. 303 

the dilator can not be worn, recourse should be had to opera- 
tion. 

Sims divided the superficial fibers of- the sphincter vaginae — 
the bulbocavernosus muscle. With the patient anesthetized, 
two fingers of the left hand are passed into the vagina to stretch 
the ostium. An incision about two inches long is made on 
each side of the fourchet, extending from half an inch above 
the ostium to the raphe of the perineum. The ostium is thor- 
oughly plugged with gauze, which is kept in position by a T 
bandage. This plugging is important to prevent hemorrhage. 
The gauze is removed the following day, after which the glass 
plug should be worn a portion of each day for several weeks. 

For incision forcible stretching may be substituted. This 
is accomplished by introducing the thumbs (Tilt) or several 
fingers of each hand (Hegar) and forcibly separating them 
until the muscular fibers yield under the traction. This pro- 
cedure affords the advantage that it is bloodless and that it 
leaves no granulating wound, to cause a cicatrix. The gal- 
vanic current has proved beneficial. Constitutional treatment 
should always be combined with the local measures. Quinin, 
arsenic, and strychnin should be given. Outdoor exercise and 
change of scene should be encouraged and complete sexual rest 
enjoined. 

329. Vulvo- vaginitis is an inflammation of the vulva and 
vagina, most frequently found in young girls, and, in the great 
majority of cases, is believed to owe its origin to the presence 
of the gonococcus. Robinson,* in fifty-four cases of vulvitis 
in children, mostly under five years of age, was able to find 
cocci in the pus cells, which corresponded to the gonococci in 
forty-one. It may also be induced by want of cleanliness, 
by the decomposition of the natural secretions, and by the 
entrance of pinworms where proper cleanliness after stool is 
neglected. The importance of the condition is too frequently 
underestimated. The infection can extend to the uterus and 
even pelvic peritoneum, producing changes which condemn the 
individual to suffering all her menstrual life and often render 
her sterile. The principal symptoms are pruritus, painful 
micturition, and a profuse yellowish watery discharge, which 
constantly soils the clothing of the child, and keeps the vulva 
irritated. The intense pruritus may readily generate the habit 
of masturbation. 

The infection may be spread by the hands, towels, linen, 
and bath. In children's asylums it is not uncommon to find 
large numbers of girls thus affected. • 

* "Tr. Lond. Obst. Soc," Jan. 4, 1898. 



304 GYNECOLOGY. 

The condition is frequently complicated by ophthalmia, 
peritonitis, and arthritis. 

Treatment should be energetic. In the acute stage it con- 
sists in rest in bed, a light diet, and free evacuation of the bowels. 
The urine should be rendered bland, and cold applications 
should also be employed. Severe pain and burning can be 
obviated by local applications of cocain, several hot sitz baths, 
and careful irrigation two or three times daily. 

In irrigation, cocain may be first applied. This can be 
followed by alkaline or antiseptic agents, potassii perman- 
ganate (i : 4000 to I : 1000), silver nitrate (i : 2000), protargol 
(0.5 to I per cent.). The irrigation should be made through 
a soft-rubber catheter introduced into the vagina. If the 
vagina does not drain well, the hymen should be stretched, 
to remove any obstruction. After irrigation, the parts should 
be dried and a mild ointment applied. The vulva should be 
covered with a sterile dressing, which should be burned upon 
removal. The child and her attendant should be impressed 
with the danger of carrying the infection to the eyes. 

330. Vaginitis, elytritis, or colpitis, is an inflammation of 
the mucous membrane of the vagina. The mucous membrane 
of the vagina closely resembles the structure of the skin, having 
few, if any, submucous glands. It consists of connective tissue 
surmounted by papillae covered with several layers of squa- 
mous epithelium. A longitudinal ridge is formed upon the 
anterior wall, from which rug^, or folds, like the teeth of a 
comb, extend upon each side. This formation is less distinct 
upon the posterior wall. The central projections are known 
as the anterior and posterior columns. The former generally 
terminate below, in a rounded protuberance, called the vaginal 
tubercle, situated immediately above the meatus urinarius. 
Sometimes the anterior column is divided by a furrow into 
two portions. The rugae aid in promoting sexual excitement, 
and probably contribute to vaginal enlargement during preg- 
nancy and parturition. They disappear toward the upper 
part of the canal. The vagina receives its blood supply from 
the vaginal, uterine, internal pudic, and vesical arteries — 
branches of the anterior division of the internal iliac. The 
vagina is surrounded by a venous network or plexus, which 
communicates with those of the vulva, bladder, rectum, uterus, 
and broad ligament, and finally empties into the internal iliac 
veins. 

The lymphatics of the lower fourth communicate with 
the superficial lymphatic glands ; those of the upper three-fourths, 
with the internal iliac glands. 

The nerves are derived from the sympathetic, and form 



IXFLAM.MATIOXS. 305 

Upon each side of the vagina a plexus which communicates 
with the inferior hypogastric. 

The arrangement of the epithehum and the absence of 
glands render the vagina much less vulnerable to infection 
than either the uterus or vulva. 

We have already referred to the normal secretions of the 
genital tract. Doderlein distinguished between the physio- 
logic and pathologic secretions of the vagina. The former 
is markedly acid, dependent upon the presence of a bacillus 
which produces lactic acid. The latter may be feebly acid, 
neutral, or alkaline, and contain a variety of micro-organisms — 
saprophytic and pathogenic. Probably fifty per cent, of preg- 
nant women have this pathologic secretion, in which germs 
flourish, and from which auto-infection is possible. The demon- 
stration of the truth of this assertion greatly simplifies the 
study of the processes of infection. 

The vaginal discharge becomes alkaline during the menstrual 
period, during the puerperium, and in many cases of leukorrhea 
— a condition which is more favorable for the growth of micro- 
organisms and the infection of the genital tract. Doderlein's 
assertion, however, does not correspond with the results of 
the researches of Menge, Kronig, and Walt hard. 

Kronig's investigations were confined to pregnant and 
puerperal women, and consequently are not a proper subject 
for consideration under gynecology further than to note his 
conclusion that the distinction between the physiologic and 
pathologic secretions is not determinable. He asserts that 
all secretions alike contain no pathogenic germs. All secre- 
tions are equally germicidal, though the vitality of the germ 
differs. It takes twice the time to kill the staphylococcus 
that it does to destroy the streptococcus. The vagina infected 
with germs will become aseptic in two or three days. The 
cause of this bactericidal power is as yet undetermined. It 
is not chemic, because it occurs whether the secretion is faintly 
or strongly acid ; it is not believed to be due to a special bacillus, 
although some micro-organisms are known to be antagonistic 
to others. If it results from leukocytes, it must be due to a 
property independent of their contractile power, for the action 
continues after their subjection to a heat which would destroy 
the latter. The want of oxygen in the vagina will not explain 
it, for the staphylococci and streptococci are anaerobic — i. e., 
grow independent of oxygen — and yet are killed. It is not 
mechanical, because particles of carbon and mercurv are re- 
moved much more slowly. Possibly all these factors may 
unite to establish germicidal action. Kronig presents a very 
important practical observation, which is that a solution of 

20 



306 GYNECOLOGY. 

corrosive sublimate for irrigation destroys the germicidal action, 
probably by precipitation of albumin, while plain water but 
lessens it. A necessary inference is that prophylactic injec- 
tions of corrosive sublimate are prejudicial when the secre- 
tion is normal. Menge, in his investigations upon the non- 
puerperal, introduced pyogenic micro-organisms into the vagina 
in eight women, and found that the vagina cleansed itself from 
these organisms in periods varying from two and one-half 
hours to three days. The factors which compass this germi- 
cidal action are various forms of bacteria and their products, 
an acid secretion, possibly serum action, and the absence of 
oxygen. This activity is weak in infants, and is lessened by 
menstruation and by increased secretion from either the cervix 
or the body of the uterus, or even from the vagina. It is de- 
creased when the vulva is patulous or the uterus prolapsed, 
and at the menopause. 

Walthard has directed attention to the influence of change 
of pabulum in restoring the lost virulence of micro-organisms. 
He inoculated the streptococcus into the ear of a rabbit with- 
out unfavorable results, unless the ear was ligatured to lessen 
tissue resistance, when a streptococcus from the vagina became 
as virulent as those found in puerperal fever. It is possible 
that an innocuous streptococcus may thus be restored by the 
tissues during the puerperium, and similarly in gynecologic 
operations in which there is bruising of all the tissues, as in 
the enucleation of fibroids. 

331. Varieties. — Vaginitis may be divided into simple and 
specific (gonorrheal). The latter is exceedingly important 
because of its intractability and its tendency to extend. The 
distinction between acute and chronic is merely one of degree. 
Special varieties named are emphysematous, exfohative, dys- 
enteric, phlegmonous, diphtheric, and senile, but these are un- 
necessary distinctions. 

The etiology and pathology have undergone some con- 
sideration in our discussion of the action of micro-organisms. 
Of these, the gonococcus is most important, for upon its dis- 
covery will frequently depend the diagnosis. It was discovered 
and described by Neisser. The recognition of its presence 
in the secretion is diagnostic, but its absence can not be consid- 
ered a positive indication that the secretion is of other than 
gonorrheal origin. 

332. Pathology. — In simple vaginitis slight elevations of the 
mucous membrane occur, producing a granular surface. The 
granulations are produced by groups of papillae, which are 
infiltrated with small cells; as a consequence, the papillae swell 
up and push before them the stratified squamous epithelium. 



INFLAMMATIONS. 307 

Superficial layers are shed. Later, the surface becomes more 
level, from thinning of the superficial covering. With the 
vaginitis of pregnancy not infrequently an emphysematous 
condition of the mucous membrane is associated. These ele- 
vations have been described as cysts containing a gaseous fluid. 
The gas consists of air and trimethylamin. Ruge says the 
gas is situated in the cellular tissue, while Zweifel says they 
are vaginal glands the ducts of which have become closed. 
A similar condition has been observed following the climacteric. 
The exfoliative, dysenteric, or diphtheric vaginitis presents 
localized patches or an inflammation of the whole vagina. 
In the latter condition the mucous membrane becomes so swollen 
that it is with difliculty the finger can reach the cervix, which is 
also thickened and covered with an exudation. 

Senile Vaginitis. — After the menopause the epithelial tissue 
is desquamated, the papillse atrophy, and the raw surfaces 
cause obliteration of a large portion of the vagina. It often 
causes curious constrictions of the upper vagina, rendering 
the canal frequently cone-shaped, with the small end above, 
which discloses the cervical opening as a mere dimple. Bands 
of contracting scar tissue are often seen, which divide the vagina 
into loculi. Desquamation of the epithelium occurs. This 
is probably produced by defective nutrition, and, later, granu- 
lations develop. X loss of elastic tissue also occurs, with an 
increase of connective tissue, which results in cicatricial con- 
traction. The same process can cause occlusion of the cervical 
canal subsequent to the menopause. 

Specific Vaginitis. — The most important cause of vaginal 
inflammation is gonorrheal infection. This produces an in- 
tractable form of vaginitis, which may continue for months, 
or even for years. It may extend over the mucous membrane 
of the uterus to the tubes, ovaries, and peritoneum, produc- 
ing endometritis, salpingitis, pyosalpinx, ovaritis, and pelvic 
peritonitis. 

333. Etiology. — Vaginitis is produced by gonorrheal infec- 
tion; irritating discharges from the uterus; the contents of 
perivaginal abscesses; the contact of urine or feces from fis- 
tulae; vaginal injections, too hot or too cold, or those contain- 
ing injurious chemic agents; badly fitting pessaries; decom- 
posing tampons; eft'orts to produce abortion or awkward at- 
tempts at sexual intercourse; and the exanthemata; and it 
may complicate typhus, smallpox, and scarlet fever. Diphtheric 
patches have been observed in a number of diseases, particularly 
in the puerperal state. Localized patches are seen in fistulas, 
in carcinoma, and about badly fitting pessaries. The disease 
is induced by the habits of the patient. The free use of alcohol 



308 GYNECOLOGY. 

produces the granular form of the disease. The gouty or rheu- 
matic diathesis is a predisposing cause. 

334. Symptoms. — Vaginitis is characterized by a sensation 
of burning, heat, and itching in the vagina; pain in the pelvic 
floor, increased by exercise; frequent desire to evacuate urine, 
with not infrequently scalding. A profuse mucopurulent leu- 
korrhea soon occurs. These symptoms are present in both 
the simple and specific varieties. In the latter the disease 
begins as an acute infection within from twenty-four to forty- 
eight hours after exposure, with itching of the urethral orifice, 
increased desire to urinate, a sensation of heat about the vulva, 
and burning and scalding upon passing urine. Generally, 
the tenderness and discharge are moderate; occasionally, throb- 
bing is substituted. The distress is increased by walking, even 
by moving the limbs, and by the slightest touch of the finger. 
The urethral orifice is reddened and slightly swollen, and a drop 
of thick mucus or mucopus can be pressed out. After one or 
two days the entire urethra is exquisitely tender, and the orifice 
is swollen, intensely red, and bathed abundantly with pus. 
Pus and blood can be extruded from the vagina by pressure 
over the urethra. The hymen, vestibule, and labia become 
swollen, edematous, and eroded, and are covered with pus 
and exudate. At the end of a week the acute symptoms have 
subsided, the discharge is abundant, and when the parts are 
neglected they become eczematous and cause a disagreeable 
odor. The vulva may regain its normal appearance in two 
weeks, while the discharge may continue for three or four weeks, 
or even longer. Infection of the vaginal follicles and of the 
vulvovaginal glands is not infrequent. The inguinal lymphatics 
become swollen, and may even suppurate. In the early part 
of the attack the gonococci are present to the exclusion of all 
other forms of bacteria, but later they may entirely disappear. 
The disease shows a marked tendency to invade the deeper 
and more important organs by the continuous mucous mem- 
brane. 

335. Diagnosis. — Upon separation of the labia a profuse 
discharge is noticed, covering a reddened, thickened, and rough- 
ened or granular mucous membrane. The speculum reveals 
the vaginal mucous membrane as a red, swollen, smooth, velvety 
surface, from which the rug^ have disappeared; or the redness, 
as well as the discharge, may be present only in patches. The 
cervix should be inspected, as the infection generally begins 
in it. The differential diagnosis between simple and specific 
vaginitis is often difficult. The history of a distinct infection 
would be valuable, but it is often too delicate a subject for 
interrogation. It may be suspected from the sudden onset 



INFLAMMATIONS. 309 

of the attack, associated with urinary symptoms, a protracted 
course, and obstinate resistance to treatment. The inflamed 
urethra and ducts of the vestibule and the orifice of Bartholin's 
ducts, and not infrequently the formation of cysts or abscesses 
in the ducts or glands, with swelling of inguinal glands, afford 
additional confirmation. The recognition of the gonococcus 
by culture and microscopic investigation renders diagnosis 
certain. The absence of the gonococcus is not proof positive 
of nongonorrheal origin, for the gonococcus may disappear 
from the secretion. 

Even when the specific origin can be determined beyond 
peradventure, caution should be exercised in the expression 
of an opinion, as it may cause serious social unhappiness. The 
diagnosis of simple vaginitis will not be sufficient, but the 
physician should carefully interrogate the various structures 
to determine, if possible, the exact cause. Pelvic abscesses, 
discharging into the vagina, have been mistaken for vaginitis. 

336. Prognosis. — The ease and rapidity with w^hich vaginitis 
can be cured will depend upon the cause. The milder cases 
can be confined to the external genitalia, or may disappear 
even after the Fallopian tubes have become affected. In 
the more severe forms the entire genital tract may be rapidly 
involved, and portions of the tract may retain the disease and 
reinfect other portions. The general health is impaired in 
the chronic cases. The ovum, when it can enter, may find 
the uterus unfitted for its retention and, therefore, an abortion 
may result. Preexisting gonorrhea is said not to disturb the 
first two weeks of the puerperium, but subsequently there is 
a marked tendency for the germs to develop renewed virulence 
and to invade the healthy structure. 

337. Treatment. — When the disease is in its acute stage, 
the patient should be kept absolutely quiet in bed. Sexual 
activity should be suspended, as well for the interests of the 
patient as for the prevention of further propagation of the 
disease. The diet should be confined to non-stimulating articles. 
Alcoholic stimulants, peppers, and various other condiments 
should be prohibited. Saline laxatives are advisable, and 
the patient should be encouraged to drink largely of emollient 
liquids or alkaline waters. 

Local applications should consist of hot sitz baths, alkaline 
douches, and of a saturated solution of boric acid in hot water, 
given for fifteen to twenty minutes out of every two or three 
hours during the day, and every four while the patient is re- 
cumbent at night. The ordinary fountain syringe serves well, 
or a piece of rubber tubing weighted at one end and provided 
with a clip and nozle at the other. The weighted end, with 



310 GYNECOLOGY. 

the coiled tube, is placed in a basin of water above the level 
of the bed, the clamp applied, and the end of the tube with- 
drawn and introduced into the vagina. The clip opened, the 
water is siphoned out as long as the external end is kept below 
the level of the basin. When the acute symptoms have sub- 
sided, douches should be given every three hours for the first 
two weeks. These douches may consist of solutions of subli- 
mate I : 4000, potassium permanganate i : 4000, carbolic acid, 
lysol, or creolin, protargol 0.5 to i per cent., mercurol 2 per 
cent. After the period mentioned the strength of the fluid 
can be doubled and the frequency of the applications is lessened, 
now employing them four times daily. The dry treatment 
consists in cleansing the surface with a douche or by washing 
the vagina through a speculum; after which, dry and pack 
with borated or iodoform cotton, and repeat every eight hours 
until the secretion is checked, when it is given twice daily. 
A dry absorbent dressing must be applied to the vagina every 
two hours. 

Astringent douches are substituted in chronic cases and 
after the subsidence of the acute stage. Cleanse and dry the 
vaginal walls and paint with silver nitrate solution (3j : foj), 
followed by a tampon saturated with a solution of bismuth 
in glycerin, which keeps the walls separated. Fritsch recom- 
mends zinc chlorid (gr. ij : foj). A one per cent, solution of 
lead acetate, zinc sulphate, or alum sulphate, potassium per- 
manganate (i : 2000), or painting the surface with undiluted 
tincture of iodin are serviceable. Acceptable powders are 
equal parts of tannin and iodoform, and bismuth subnitrate 
and chalk, retained with a tampon. In senile vaginitis cleanse 
with a saturated boric acid solution. Tampons may be satu- 
rated with a 0.5 per cent, solution of lead acetate, or strips 
of lint may be saturated in a five per cent, solution of carbolic 
acid in glycerin or smeared with zinc ointment. Vaginal sup- 
positories of tannin and iodoform, each five per cent. ; zinc 
oxid, ten per cent. ; or lead acetate, two per cent., may be em- 
ployed. When the condition is very chronic, spray through 
a speculum with a two per cent, solution of silver nitrate. The 
spray drives the medicine into the crypts and folds, and is 
far more effective than swabbing. I have derived more benefit 
from tampons anointed with ichthyol in lanolin (1:4). It 
causes a desquamation of the entire epithelium of the vagina 
and is destructive to the gonococcus. 

338. Urethritis. — Inflammation of the urethra is an ex- 
ceedingly painful, but not an unusual, complication of pelvic 
abdominal procedures in which the catheter has been employed. 

Varieties. — It may be manifest as a simple hyperemia, an 



INFLAMMATIONS. 311 

acute catarrhal urethritis, a chronic interstitial urethritis, or 
a granular or follicular urethritis. Associated with the ure- 
thral inflammation occasionally occur ulceration, fissures, and 
a sacculated condition of the urethra. 

339. Hyperemia may result from injury during a difficult 
labor; from uterine displacement and uterine gro\vths affecting 
the pelvic circulation; from varicose veins, irregular urination, 
excessive coitus, or long-continued irritation. Probably the 
most frequent cause of hyperemia which ma}^ continue until 
inflammation results is the repeated use of the catheter. So 
probable is such a result that the majority of operators prefer; 
if possible, to have the patient evacuate the urine unaided. 
When the employment of the catheter is necessary, the operator 
should have the nurse introduce the instrument for the first 
time in his presence, so that he can observe what precautions she 
employs and determine the ease with which she can accomplish 
the procedure. The instrument should never be introduced by 
touch, but always by sight. The vulva and the vestibule are 
generally covered with discharge, which may have decomposed 
and become infected by micro-organisms capable of producing 
serious discomfort when carried into the bladder. 

The labia minora should be separated and the vestibule 
sponged with absorbent cotton saturated with an antiseptic 
solution. The instrument, preferably of glass, should be per- 
fectly smooth, with no rough or cutting edges. It should be 
boiled, kept in an antiseptic solution, and previous to its use 
washed with sterile water. It is then anointed with carbolized 
vaselin and carried by gentle pressure upward and backward, 
without exercising any force. If the passage of the catheter 
is obstructed, withdraw and reintroduce it, as the instrument 
may have entered one of Skene's follicles. 

Even with the exercise of every precaution the urethra 
is often so irritated by the frequent introduction of the catheter 
that the patient may suffer more distress than from the con- 
dition for which the operation w^as performed; consequently 
whenever the patient can evacuate the bladder unaided, she 
should be encouraged to continue to do so, as the contact of 
healthy urine with a plastic wound, if the precaution is ob- 
served immediately to irrigate the latter, is less harmful than 
would be frequent catheterization. 

In operations upon the bladder which require the urine to 
be frequently evacuated, a self -retaining catheter should be 
left in place several days. A soft-rubber instrument with 
a flange upon its vesical end is most serviceable. It can be 
plugged, permitting the urine to collect for two or three hours. 
It should not be permitted to remain longer than forty-eight 



312 GYNECOLOGY. 

hours without removal and careful cleansing. The ordinary 
glass catheter, with a long rubber tube attached, in my ex- 
perience, does equally well. 

340. Acute Catarrhal Urethritis. — The mucous membrane 
becomes thickened; its papillae are hypertrophied and are 
covered with an imperfectly developed epithelium. At points 
the latter is desquamated and the papillae are enlarged. This 
may result in the formation of a considerable sized mass, which 
projects from the surface frequently by a pedicle — the urethral 
caruncle. 

The acute disease can arise from long-continued and re- 
peated hyperemia or from traumatism, but it most frequently 
results from gonorrheal infection. The urethra is often the 
first point affected. 

Symptoms. — The onset of the acute attack is at first made 
known by itching or smarting of the urethral orifice, as the 
contact of the urine gives a sensation of a hot scalding liquid 
and urination is followed by intense burning along the course 
of the urethra. The meatus becomes red and swollen, then 
dark red and pouting. It is tender to the touch, and pressure 
along the urethra causes a few drops of mucopurulent or puru- 
lent secretion to be discharged. If the disease does not extend 
to the bladder, the symptoms soon subside or disappear. 

Diagnosis. — The condition should not be confounded with 
cystitis. The tenesmus of urethritis can be controlled; it is 
attended with scalding, but is relieved by urination. In cyst- 
itis the tenesmus is uncontrollable, unrelieved by urination, 
and there is no urethral burning. 

341. Chronic catarrhal urethritis is very generally an inter- 
stitial inflammation. The membrane is thickened and the 
canal narrowed, not infrequently permanently so, which results 
in a stricture. 

Symptoms.— Vrinsition is frequent. Temporary retention 
of urine may, however, be caused by a spasmodic stricture. 
The latter is greatly aggravated by frequent coition or pro- 
longed exercise. The thickening of the urethra is apparent 
upon passing the finger down the anterior wall of the vagina 
along its course. A small sound can be passed through the 
urethra, while the introduction of a large one meets with re- 
sistance and produces severe pain. 

342. Follicular inflammation involves the follicles about 
the orifice of the urethra and Skene's glands. The latter are 
two tubules which will admit a No. i probe (French scale), 
and are situated in the floor of the female urethra, extending 
upward from the meatus about one or two centimeters. In 
the normal condition the orifices of the tubules are three milli- 



INFLAMMATIONS. 



313 



meters within the meatus, but with the urethra sHghtly pro 
lapsed and the meatus everted, the orifices may be exposed 
to view. The upper ends of these canals terminate in a number 
of divisions, which project into the muscular wall of the urethra. 
These tubules occasionally become so enlarged as to permit 
the introduction of a small catheter. If such an instrument 
were forcibly introduced, it would tear through the tubule 
and establish a false passage. Such a passage might enter 
the urethra or pass beneath it into the tissue and thus enter 
the bladder. The follicles and tubules about the urethral 
orifice may become inflamed, with the consequent discharge 
of mucus and pus. The mucous membrane may become thick- 
ened or the orifices closed. The latter will 
result in the formation of small cysts. 

Sympto7ns. — The symptoms are great 
tenderness; discomfort in sitting, stand- 
ing, or walking; dyspareunia; stinging 
pain; a sensation of heat; and frequent 
and painful micturition. The orifice of 
the meatus is partly everted, with red, 
puffy folds, which simulate caruncle, and 
with erosion of the labia minora and of 
the edge of the meatus. A few drops of 
purulent discharge can be extruded by 
pressure along the urethra. 

343. Ulceration is produced as a result 
of traumatism, from calculi, unskilful use 
of the catheter, specific infection, or the 
presence of the diphtheric or the venereal 
poison. 

During the passage of a calculus, or 
while in labor, injury, laceration, or over- 
distention of the middle portion of the 
canal occurs, with contraction of the mea- 
tus. A small portion of urine and mucus is retained, which 
decomposes, and results in the development of inflammation 
and in the production of a condition simulating an abscess. 

Symptoms. — The most prominent symptom is dysuria, which 
becomes chronic. The meatus is large, of a deep red color, 
granular appearance, and sensitive to pressure. The passage 
of an ordinary sound is readily accomplished, but is attended 
with pain. Sometimes a drop of blood is discharged. The 
sacculated form is associated w4th a large discharge of pus, 
particularly when pressure is made along the urethra. Even 
when the discharge of urine is perfectly clear, pressure will 
cause a considerable discharge of pus. 




277. — Urethra Laid 
Open with Probes, 
Distending Skene's 
Glands. Posterior 
Wall Divided.— 
(Byford, after 
Skene.) 



314 GYNECOLOGY. 

344. Vesico-urethral fissure holds an intermediary position 
between cystitis and urethritis, and strikingly resembles both. 
Its cause is undetermined. The fissure is situated at the in- 
ternal meatus, and resembles a crack in the lip or an ulcer 
similar to that which is found in fissure of the anus. The 
fissure is usually considered as being situated in the neck, but, 
as a rule, two-thirds of it is in the urethra. Only the upper 
end of it extends into the bladder. It may occur at part of 
the circumference of the urethra, but, according to Skene, it 
is, in the majority of cases, situated upon the right side. In 
length it is from six millimeters to one centimeter, and is from 
two millimeters to four millimeters in width at the widest part. 
It is deeper at either end. The deepest portion, yellowish- 
gray in color, resembles an indolent ulcer, while its edges are 
red and inflamed. Through an endoscope it looks like a fresh 
tear, the edges of which are abrupt, elevated, and indurated. 
Its situation explains the attendant discomfort. In any other 
portion of the urethra it produces little inconvenience beyond 
a smarting sensation, but at the junction of the bladder and 
urethra it is subject to constant though slight pressure, which 
causes severe and continuous pain. The portion of the fissure 
extending into the bladder is exposed to irritation from contact 
with the urine, producing a constant desire to urinate, a sen- 
sation of burning at the neck of the bladder, acute pain during 
and immediately following micturition, and severe tenesmus, 
causing the patient to continue straining efforts after empty- 
ing the bladder. The pain and burning immediately follow- 
ing micturition are often intense. Subsequently, it partly 
subsides, to return with the accumulation of a small quantity 
of urine. If the patient resists the inclination to urinate, the 
distress is greatly aggravated. 

345. Diagnosis of Urethral Inflammations. — The recognition 
of inflammation of the urethra is often difficult, because it is 
frequently complicated by inflammation of the bladder. Acute 
catarrhal inflammation of nonspecific origin usually begins 
gradually, and is often preceded by uterine or vesical symptoms, 
while the gonorrheal variety appears abruptly, and is preceded 
or attended by acute vaginitis or vulvitis. 

In both varieties urination is painful. Sharp scalding is pro- 
duced by urine passing over the inflamed surface, but the desire 
to urinate is not so frequent or urgent as in cystitis. Often the 
urine is long retained, for fear of the pain occasioned by its 
evacuation. 

Slight hemorrhage is occasionally noticed, the urethral 
origin of which is evident from it being unmixed with urine, a 
few drops oozing from the external meatus subsequent to urina- 



INFLAMMATIONS. 315 

tion. Urethral discharge is common, and, except just after 
■urination, it can be extruded from the orifice by pressing upon 
the urethra from the vagina. [Microscopic examination of 
the discharge may reveal the presence of gonococci, which 
determines the nature of the urethritis. Absence of this germ, 
however, is not positive proof against the gonorrheal origin. 
To exclude cystitis, introduce the catheter, allow some urine 
to escape to wash away the mucus introduced with the in- 
strument, and retain the remainder, which will be found free 
from sediment. Pressure along the urethra from the vagina 
is painful in urethritis, while pressure over the bladder, unless 
complicated by cystitis, is not uncomfortable. 

In chronic urethritis the urethra is less sensitive, but it 
will be noticed as a somewhat thickened cord when examined 
from the vagina. 

In granular erosion the pain during micturition is excruciat- 
ing, it is associated and followed by tenesmus, and is more 
likely to be found in old persons. 

The character of the disease is assured by its history and 
by the appearance of the urethra. Fissure, urethritis, and 
cystitis are distinguished, the latter especially by examination 
of the urine. Fissure alone is free from all the products of 
cystitis. Urethritis is excluded and the fissure detected by 
the use of the endoscope. The endoscope is more satisfactory 
than the ordinary open instrument because it exposes the sur- 
face of the fissure, which Avould be overlooked with the open 
end instrument. As a rule, the pain in fissure is more circum- 
scribed than in either urethritis or cystitis, and in many cases 
more acute. 

The maximum of pain in fissure follows urination, while 
in cystitis there is a sense of relief. In urethritis the most 
severe pain occurs during the act of urination. It then sub- 
sides slowly. 

346. Treatment of Urethral Inflammations. — In urethral 
hyperemia render the urine bland and unirritating by the 
exclusion of acids and stimulants from the diet and by the 
administration of saline cathartics. Relief is enhanced by 
giving ten grains of benzoate of ammonia or benzoate of sodium 
every three or four hours, and by the employment of hot hip- 
baths and hot vaginal douches. 

Acute urethritis, whether specific or otherwise, should be 
treated upon the same principles as in gonorrhea of the male. 
The treatment consists of constitutional and local measures. 
Internally, salicylic acid in ten-grain doses lessens the dis- 
charge. Douche the urethra frequently with hot water through 
a reflex catheter, so that the current flows back from a cap on 



316 GYNECOLOGY. 

the end of the instrument. Later, inject from one-half of 
one to one per cent, of carboHzed water; sublimate, gr. -^-q, to aq., 
f5j ; silver nitrate, gr. -J-, to aq., fSj ; or zinc chlorid, gr. x, to aq., 
foj ; preceded, when injection is painful, by the instillation of 
a solution of cocain with a pipet. 

In making urethral applications it should not be forgotten 
that the canal will hold but from ten to fifteen drops. If a 
larger quantity is thrown in by the pipet, it flows into the blad- 
der. A strong solution of silver nitrate (gr. x-xv to aq. fi5J) may 
be applied by pipet or applicator. 

Internally may be administered those remedies which will 
have an inhibitory influence through the urine. These so- 
called blennorrhagic remedies are: copaiba, cubebs, sandal- 
wood oil, urotropin, and aminoform. 

The itching of subacute and chronic urethritis may be alle- 
viated by applications of different combinations of chloral or 
hydrocyanic acid, as in the following prescriptions: 

H. Chloral, J^iv 

Lanolin, ^j. M. 

Ft. ungt. 

R . Chloral, 

Camphor, aa gr. xxx 

Lanolin, ^ j. M. 

Ft. ungt. 

B: . Acid, hydrocyan. dil., 5 j 

Plumbi acet. , gr. xv 

Glycerin, f Jj. M. 

These remedies may be brought in contact with the affected 
surface by the applicator. A suppository or bacillus of cocain 
in cacao-butter, or in combination with lead acetate, will give 
relief. These bacilli should be introduced into the urethra 
two or three times in the twenty-four hours, preferably after 
urinating. In prolonged chronic disease which has resulted 
in thickened walls and a more or less contracted canal, the 
dilatation of the urethra by bougies once or twice weekly will 
be beneficial. 

The bougie may be anointed for introduction with mercuric 
oleate, the official ointment of mercury, or any other medicinal 
agent which will have a beneficial influence upon the mucous 
surface. M. Julien, of Paris, applies ichthyol by dipping into 
it a cotton-wTapped probe, which is passed and repassed into 
the urethra several times. This agent has a destructive in- 
fluence upon the gonococcus. 

Granular erosion is best treated by brushing pure carbolic 
acid or silver nitrate (gr. xv to aq., fSj) over the surface. This 
should be repeated in eight or ten days. The urethra should 



INFLAMMATIONS. 317 

be previously dilated. Following the subsidence of the acute 
symptoms, a few drops of a solution of zinc sulphate, gr. iv, 
fluid extract of hydrastis canadensis, foj, aq., fSiij, may be 
used twice weekly with a pipet. ]\Iercurol, 2 per cent, solution, 
has been found very serviceable. 

In fissure, instillations and injections do harm, by increas- 
ing the spasmodic contraction of the bladder, and they add 
greatly to the discomfort of the patient. 

A fissure may be exposed by a fenestrated speculum, and 
dusted with calomel, finely pulverized iodoform, or bism.uth 
subnitrate, or the mitigated stick of silver nitrate may be em- 
ployed. Incision of the fissure as performed in anal fissure 
is successful. The urethra should have been previously dilated. 
Dilatation is one of the most effective methods of treating 
fissure. The precaution must be exercised, however, not to 
overdilate the urethra and thus produce permanent incon- 
tinence. 

Follicular urethritis is most eftectively treated by splitting 
up the tubes their entire length. This may be done with the 




Fig. 2 78. —Reflex Catheter. 



J 



thermocautery, or they mav be cauterized with carbolic acid 
and subsequently treated with milder agents, as in urethritis. 
In such cases, however, splitting up the canal is a prerequisite 
to cure. 

347. Cystitis is an inflammation of the mucous membrane 
of the bladder, and may be either acute or chronic. 

Etiology. — The bladder is in intimate muscular relation 
with the uterus, as well as dependent upon the same nerve- 
centers and ganglia for its nervous distribution. A portion 
of the bladder lies in direct contact with the cervix, but in 
more close relation with the vagina. It is not surprising, then, 
with such intimate relations, that the condition of the bladder 
should be aft'ected by disorders of the uterus. 

Inflammatory conditions of the bladder, if they have not 
originated from disorders of the uterus, are aggravated thereby. 
The symptoms of cystitis are more marked during menstruation 
and greatly aggravated by metritis. Vesical symptoms are 
engendered by uterine and vaginal displacements, by subin- 
volution and hypertrophy, by tumors and pregnancy. The 



318 GYNECOLOGY. 

train of phenomena thus engendered may be enumerated as: 
difficulty in evacuation; retention and decomposition of the 
urine, producing irritation, and finally cystitis. Cystitis may 
be secondary to inflammation of the kidneys, ureters, or urethra. 
Chemic modifications of the urine may result from indiscretions 
in diet, from the administration of irritating drugs, or from 
affections of the central nervous system. Inflammation is 
produced by traumatisms, injuries from the introduction of a 
catheter, or the presence within the bladder of a rough calculus. 

AVithout doubt, the most frequent cause of cystitis is in- 
fection. This may result from the deposition of bacteria by 
the blood, from the extension of inflammation from neighbor- 
ing organs, or the introduction of infection by way of the ure- 
thra. The infection is generally introduced into the bladder 
from the employment of the catheter. A violent form of cystitis 
is produced by retention of urine. A pregnant retroflexed 
uterus which has become impacted in the pelvis by pressure 
upon the neck of the bladder not infrequently leads to gangrene 
and desquamation, or to separation en masse of the entire 
vesical mucous membrane. Neoplasms, such as cancer, tuber- 
culosis, polypi, and villous tumors, will usually excite a cystitis. 

Pathologic Changes. — The mucous membrane becomes in- 
jected, particularly about the orifices of the ureters and in- 
ternal meatus. As the inflammation progresses, the entire 
mucous membrane is swollen and becomes a bright red. The 
epithelium is desquamated and patches of ulceration or hypertro- 
phied papillae appear, which bleed easily. Abscesses develop 
in the vesical wall. The micro-organism most frequently 
found is the bacillus coli communis. Disease is also induced 
by the staphylococcus, the gonococcus, and the bacillus tuber- 
culosis. 

348. Symptoms of Acute Cystitis. — Acute inflammation of 
the bladder is characterized by painful micturition; frequent 
desire to void urine, with only a few drops discharged at each 
attempt; severe vesical, and frequently rectal, tenesmus; a 
sensation of fullness or weight in the hypogastrium ; shooting 
pains in the perineum and anus; and a burning, lancinating 
pain, like a hot iron, in the urethra. These attacks may be 
almost continuous, or may, after a time, subside, to recur again 
in an hour or so. Examination by touch, whether over the 
abdomen or by the vagina or rectum, is extremely painful. 
The urine is scanty, highly colored, and becomes cloudy after 
standing. In very severe attacks the urine becomes a dark 
red color and contains blood and pus-corpuscles and uric acid 
crystals. 

Constitutional disturbances are marked. These are nervous 



INFLAMMATIONS. 319 

excitement, insomnia, and anorexia, followed by emaciation 
and loss of strength. Uncomplicated vesical inflammation 
does not cause elevation of temperature (Guy on). Partial 
or complete retention of urine is frequent. Paroxysmal pain 
results from vesical distention, and there may be frequent 
evacuation or continuous dribbling of urine without at any 
time emptying the bladder — an evidence of overflow known 
as the incontinence of retention. The course and duration 
of the disease are variable; it may subside in a few days or 
may continue alternately better and worse for weeks. 

349. Symptoms of Chronic Cystitis. — In chronic inflam- 
mation the symptoms are less pronounced, though similar to 
those of the acute disease. Micturition is frequent and pain- 
ful, often difficult. The pain is pronounced at the beginning 
of the evacuation, thus leading to delay in starting. Exposure 
to cold, dampness, changes of clothing, indiscretions in diet, 
or constipation, lead to acute or subacute attacks. The urine, 
after standing, becomes cloudy, and contains blood and pus- 
corpuscles, mucus, and uric acid crystals. If drawn with the 
catheter, it is at first clear, then turbid, and toward the last 
pus is apparently discharged. The microscope reveals leu- 
kocytes, epithelial cells, tissue debris, and salt crystals. When 
the urine stands, it becomes alkaline, and bacteria in abundance 
are found. 

Constitutional Condition. — The patient is easily fatigued, 
has no appetite, loses flesh, develops a cachexia, has repeated 
inflammatory attacks associated with fever, repeated chills, 
a more or less continuous diarrhea, profuse sweating, and, 
finally, a fatal termination results. Such a train of symptoms 
and such a termination indicate the presence of an infectious 
pyelonephritis as a complication. 

350. Cystitis of gonorrheal origin is produced by the ex- 
tension of gonorrheal infection from the urethra, possibly 
through the careless employment of the catheter, but more 
frequently from the continuation of urethritis to the bladder. 
Its principal symptoms are frequent micturition, agonizing 
pain in the acute stages, associated with changes in the quality 
of the urine; hematuria is a constant symptom, but is rarely 
profuse. These symptoms do not occur in the early stage of 
the infection. The disease is then generally much milder, 
characterized only by tenesmus. In the mucopus of the urine, 
from the associated urethritis, the gonococcus may be found. 

351. Tubercular cystitis causes symptoms very similar to 
those produced by inflammation from gonorrhea and the irri- 
tation of calculi. Hematuria is a symptom in all varieties, 
but dift'ers in tuberculosis. It appears early in the disease. 



320 GYNECOLOGY. 

and the blood is generally mixed with the last drops of lirine. 
The bleeding ceases as the disease advances. In common 
with other vesical inflammations, pain, urethral spasm, and 
retention and incontinence of urine are marked. 

352. Diagnosis of Cystitis. — Cystitis is not difficult to recog- 
nize. The frequent micturition, pain, alkaline reaction of the 
urine, large quantity of sediment, and muco-purulent appear- 
ance are ample evidence. In cystalgia and functional dis- 
eases of the bladder the urine will be found clear. Probably 
the greatest difficulty will be experienced in differentiating 
pyelonephrosis. Indeed, the infection from the kidney may 
lead to disease of the bladder and vice versa. The prognosis 
and method of treatment must depend upon the accurate 
determination of the structures involved. 

The existence of pyelonephrosis is recognized by finding 
the urine unaltered after irrigation of the bladder, while in 
cystitis it becomes clear. The condition of the urine from 
each kidney is recognized by securing the urine separately 
through catheterization of the ureters or by the employment 
of the Harris segregator. 

The careful investigation of the urine will often be sufficient 
to determine the diagnosis. Albumin is contained in the urine 
in either cystitis or pyelitis, but in very slight amount in the 
former, while it is present in quite large proportions in the latter. 

The presence of a proportionately great abundance of albu- 
min in the urine, associated with pus, should be considered 
as indicating the presence of renal disease. The most frequent 
cause is tuberculosis. The diagnosis of tuberculosis of the 
urinary tract is determined by the presence of the tubercle 
bacillus in the urine. Dr. Joseph Walsh, of Philadelphia, asso- 
ciated with Dr. Flick, in his investigations in tuberculosis, 
however, informs me that the tubercle bacillus is found much 
more frequently in the urine of the tuberculosis patients than 
is generally supposed. The great majority of these patients 
will be found not to have a tuberculous kidney, though they 
will show a catarrhal condition of the kidneys, which is mani- 
fested by pains or aching in the bones, and by the presence 
in the urine of epithelial or granular casts, pus, and sometimes 
albumin. The bacilli may be found in the urine without any 
inflammatory symptoms. In sixty non-selected tuberculous 
patients, whose urine Dr. Walsh examined, the bacilli were 
recognized in forty-four ; in thirty of these the disease was in an 
advanced stage; in ten it was considered marked, and in four, 
was only incipient. In patients in the advanced stages of 
the disease it is rarely that the bacilli will not be found in the 
urine. In five of the fort v-f our cases above cited, tubercle 



INFLAMMATIONS. 321 

bacilli were found in the urine, but not in the sputum, though 
the presence of a pulmonary lesion was recognizable. I have 
quoted Dr. AYalsh fully, because his investigations seem to 
demonstrate that the presence of tubercle bacilli in the urine 
can not be accepted as evidence of the existence of a true renal 
lesion. The usually recognized difficult}^ of finding the bacilli 
in the urine is my justification for quoting here Dr. Walsh's 
method of examination : ' ' Six fluidounces of urine are cen- 
trifugated in a water motor centrifuge ; the sediment is then 
poured on one or two cover-glasses and allowed to dry thoroughly 
(twenty-four to forty-eight hours). The process is complicated 
by an excess of the crystalline sediment, which may render it 
impossible to find the micro-organism. In such cases, there- 
fore, the sediment secured by centrifugation should be dis- 
solved in water, a weak nitric acid, or a caustic potash solution, 
and again subjected to the centrifuge. In rare cases the sedi- 
ment may resist any one or all of these solutions. After dry- 
ing, it is fixed to the cover-glass by passing the latter through 
a flame two or three times, repeating this procedure twice, 
at intervals of a minute or two. The procedure for determina- 
tion of the bacillus in urine requires more heat than the corre- 
sponding examination of the sputum. Even after the pro- 
cedure for fixing given, the sediment will occasionally be washed 
off by the running water, and the specimen thus destroyed. 

''The specimen is stained with carbol-fuchsin for three to 
five minutes or longer, washed in turn with 95 per cent, and 
absolute alcohol for one to three minutes, decolorized and 
count erstained with Gabbet's solution. The greater number 
of foreign elements in the urine, some of which hold the fuchsin, 
makes a larger experience necessary for the recognition of the 
bacilli than is requisite in sputum. 

' ' The organisms must be absolutely typical to render the 
diagnosis certain." 

In examining over the abdomen of a patient suft'ering from 
tuberculous cystitis, greater pain is experienced by suddenly 
withdrawing the hand pressure than is produced by deep pal- 
pation. A cystoscopic exploration of the bladder will reveal 
the extent of involvement and amount of tissue destruction. 
Tuberculous cystitis may supervene upon the gonorrheal, 
without cessation of the latter. 

Primary vesical tuberculosis is manifested by a very ir- 
ritable bladder, frequent and painful micturition followed by 
the passage of a few drops of blood. Such symptoms may 
subside, to be followed by an aggravated attack. The pres- 
ence of pus in the urine indicates pre-existing disease, which 
may have been unsuspected. The progress of the disease is 
21 



322 GYNECOLOGY. 

more rapid when complicated by the discharge of pus, the 
presence of a fistula, or the existence of pyelonephritis. The 
latter complication should be suspected when the urine shows 
the presence of a large pus sediment, inordinate quantities of 
albumin, and if the patient gives a history of incontinence of 
urine and repeated exacerbations of high temperature. Polyuria 
is a most constant symptom of urinary tuberculosis. 

Gonorrheal cystitis is associated with evidences of infection 
of other portions of the genito-urinary tract, particularly the 
urethra, glands of Bartholin, cervix and pelvic organs, which 
have preceded the vesical disease. The gonococcus can generally 
be found. 

A form of inflammation of the bladder, known as mem- 
branous cystitis, is a condition in which there is more or less 
extensive exfoliation of the bladder-wall, as in pseudo- 
membranous, gangrenous, croupous, or diphtheric inflamma- 
tion. It is always secondary to overdistention of the bladder 
from retention of urine. The mucous membrane is anemic 
during distention, but, upon the removal of the bladder contents, 
it becomes acutely congested and engorged with blood. It 
may be produced by any obstruction of the urethra. The 
most frequent causes are incarceration of a retrofiexed gravid 
uterus, unilateral hematometra, fibroid and ovarian tumors 
deeply seated in the pelvis, and loss of muscle power in low 
fevers and in septic conditions. 

The nurse or attendant may be led by the incontinence 
to overlook the occasionally enormous distention. The en- 
largement is gradual, extending above the navel, in the form 
of a tumor, which may very readily be mistaken for an ovarian 
cyst. The distention reaches its maximum when the reservoir 
can retain no more, and the abdominal pressure produces an 
involuntary discharge of the overflow, a condition which has 
been spoken of as incontinence of retention. 

Even though the bedding is constantly soaked with urine, 
the bladder is never completely emptied. The continuous 
pain, involuntary discharge of urine, a suddenly formed, gradu- 
ally increasing tumor, percussion; dulness over its site, absence 
of the uterus above the symphysis, and the projection backward 
of the anterior vaginal wall, should make plain the diagnosis. 
Constant dribbling of urine should always awaken suspicion of 
such a condition. 

Catheterization of such a patient by an ignorant midwife 
may cause the formation of a false passage, or negligence in 
the previous cleansing of the vulva will favor the entrance 
of infective agents into the bladder. No more favorable con- 
ditions for the extension of the sepsis could be imagined. 



INFLAMMATIONS. 323 

Even if cystitis did not exist, hyperemia, infection, and 
traumatism, as a result of retention, would not be surprising. 
The enormous distention of the bladder causes anemia of its 
mucous membrane, thus producing disturbance of nutrition 
and superficial necrosis. Deep necrosis is caused by bacterial 
action. All such processes favor destruction of the mucous 
membrane. The inner wall of the bladder may become partially 
or completely detached, covered with phosphates of ammo- 
nium and magnesium, and penetrated with putrescent bacteria. 
The surface of the membrane is black or gray, contains numerous 
excavations and sometimes horny concretions. The mucous 
membrane may come away in pieces or as a complete cast of 
the bladder. 

A portion of the membrane or the entire structure may 
lodge in front of the urethral orifice and completely obstruct 
the evacuation of urine. A small quantity of pus only may 
reward the introduction of the catheter. This pus has accu- 
mulated at the lower portion of the bladder, but a more forcible 
pressure of the catheter may cause it to penetrate the mem- 
brane and permit the evacuation of the decomposing urine. 
Violent tenesmus is a frequent symptom of such conditions. 
The urethra, dilated, will often permit the expulsion of the 
entire sac as a black, putrid mass. Cases have been reported 
in which complete exfoliation has taken place and the patient 
subsequently recovered good health without disturbance of the 
vesical functions. Neoplasms are differentiated from cystitis 
by the early appearance of hematuria with absence of pain, 
tenesmus, or frequent micturition. 

The quantity of blood increases near the close of micturition ; 
it may continue for days or weeks, and may suddenly cease. 
Sometimes fragments of the gro\\i;h may be discharged. He- 
maturia dependent upon tumors varies with their character. 
If the growth is benign, its progress is slow, unless the pelvis 
of the kidney and ureters are involved. 

Cystitis due to the presence of foreign bodies, such as calculi, 
is characterized by severe pain, frequent micturition, violent 
expulsive efforts, and hematuria, after active exercise. In 
arriving at a correct diagnosis, it must not be overlooked that 
very marked disturbance of the bladder may arise from the 
administration of various drugs, from the application of vesi- 
cants, especially cantharides. In such cases micturition is 
frequent and very painful, while tenesmus is marked. The 
withdrawal of the irritating cause is followed by prompt relief. 

353. The prognosis of cystitis is necessarily uncertain, and 
must depend upon the duration and character of the disease, 
extent of involvement, complications, and carefulness of treat- 



324 GYNECOLOGY. 

raent. When the disease has existed for a long time, the in- 
flammation has extended through the mucous surface, more 
or less involving the muscular coat and causing contraction 
and distortion of the organ. It can readily be understood, 
therefore, that no treatment will restore the functionating 
power of the organ. 

The prognosis is especially unfavorable when the disease 
has extended to the ureter, and especially to the pelvis of the 
kidney. Tubercular disease of the bladder also determines 
an unfavorable prospect for ultimate recovery, although I 
have seen most gratifying results when the tuberculosis was 
secondary to disease in one kidney and ureter after the removal 
of the offending organs. The favorable results in all cases 
will largely depend upon the carefulness of the treatment and 
the degree of cooperation the physician can secure from his 
patient. 

354. Treatment. — In the treatment of inflammation of the 
bladder, the aim should be, first, to remove or lessen its cause; 
second, to afford relief to pain; third, to improve the general 
condition of the patient. 

Prophylaxis. — The first indication is met most completely 
by prophylaxis, which, in all conditions dependent upon microbic 
invasion, should be the first consideration. Disinfection of 
the body, of the surroundings, of the hands, and of the instru- 
ments is necessary. The old procedure of introducing the 
catheter by touch is reprehensible. In the puerperal woman 
artificial light may be necessary. The legs should be flexed 
strongly, the better to bring the vulva into view. A small 
vessel is placed between the limbs, or the patient may be placed 
upon a bed-pan and a warm disinfectant fluid poured over 
the vulva, which may enable her to void the urine spontaneously. 
If unsuccessful, the vulva is sponged with a cotton tampon 
and an irrigation stream is directed upon the urethral orifice. 
Then the catheter is taken from a disinfecting fluid and care- 
fully introduced, to avoid pain. Occasionally, there is resist- 
ance at the internal end of the urethra, which is not over- 
come without pain. Care should be exercised in the with- 
drawal of the instrument, as the mucous membrane may be 
sucked into the eyelet of the catheter. Pushing up the instru- 
ment before its withdrawal will loosen it, when it can be re- 
moved without vesical injury. Whenever possible, the use 
of the catheter should be avoided, as, notwithstanding all pre- 
cautions, the mucous membrane of the urethra will be irritated 
by its frequent introduction, thus affording an opportunity 
for infection. 

Medical treatment to a limited degree meets all the indications 



INFLAMMATIONS. 325 

we have assigned for the treatment of cystitis. The acidity 
and tendency of the urine toward decomposition are combated 
by the use of diuretics, and by the administration of large 
quantities of the alkahne waters, such as Saratoga, Vichy, 
Seawright, Buffalo or Londonderry lithia, Carlsbad, or Seltzer. 
The salicylates are among the most efficacious remedies. Salol 
2 to 3 grains can be given every three or four hours. Strontium 
salicylate 3 to 4 grains four times daily. Some of the formalin 
compounds have been found very effective, as urotropin, grains 5 
to 10, four times daily. Probably aminoform, 5 to 10 grains four 
times daily, will give greater satisfaction. These drugs should 
be administered largely diluted. They prevent decomposition, 
remove the odor, and decrease the pain and tenesmus. They 
should not be given on an empty stomach. The diet, though 
nutritious, should exclude stimulants, acids, and condiments, 
except salt. Sugars and starches should be sparingly used, 
and in acute and severe cases it is well to restrict the patient 
to skimmed milk. In acute cases the patient should be con- 
fined to bed, and all exposure to dampness or cold should be 
avoided. In all cases care should be exercised regarding suit- 
able clothing and protection against exposure. Pain maybe 
so marked and micturition so frequent that measures must be 
instituted for its relief. Morphin or opium affords relief, but 
the pain soon returns. The remedy can not be repeated every 
two or three hours without danger of establishing the habit. 
An ice-bag over the bladder will frequently give comfort; in 
other cases the hot -water bag is better borne. 

In the more distressing cases opium may be given in com- 
bination with belladonna or stramonium; deodorized tincture 
of opium and tincture of belladonna, 10 to 15 drops of each 
every two or three hours until relief ; or suppositories of extract 
of opium, J- J of a grain, and extract of belladonna, -|-J of a 
grain, in cacao-butter — two, three, or four of these suppositories 
daily, according to the degree of pain. Relief is most quickly 
secured, however, by a hypodermic injection of -J- of a grain of 
morphin. When opium is badly borne, cocain hydrochlorate, 
I of a grain, may be given by suppositories in combination with 
the same quantity of extract of hyoscyamus. When the pain 
is limited to the urethra, it may be subdued by injecting a 
solution of cocain by a syringe with a bulb nozle. The open- 
ings about the bulb should be so situated as to direct the cur- 
rent back toward the external orifice. A celluloid is prefer- 
able to a metal syringe, because it can be used for sublimate 
and silver nitrate solutions. 

Inflammation of the neck of the bladder may be alleviated 
by the introduction night and morning of a vaginal tampon 



326 GYNECOLOGY. 

covered with an ointment containing 30 grains of extract of 
belladonna to i ounce of camphorated lanolin. 

Calculi and foreign bodies should be removed and shreds 
of membrane and casts of the bladder should be early separated 
and evacuated. 

Gonorrheal and acute cystitis are considered as requiring 
diuretics, such as the alkaline salts, alone or in combination 
with oil of birch, buchu, or triticum repens. The following 
prescription is often serviceable: 

li . Ammon. benzoat., g iij 

Tr. hyoscyami, f 3 j-ij 

Ext. buchu ■u^/itritici repens, ad f .^ ij. M. 

SiG. — A teaspoonful in an ounce of water four times daily. 

Marsh directs: 

R . Acid, oxalic, gr. xvj 

Syr. aurant. cort f .| j 

Aq. pluv., adf 5iv. M. 

SiG. — A teaspoonful every four hours. 

The bromid salts are often of value. 

Free evacuation of the bowels by salines should be secured. 
After the severe distress and pain have subsided in acute cases 
and in all chronic inflammations, advantage may be secured 
by intravesical medication. 

The bladder is irrigated through a return-current catheter 
by means of a fountain syringe: the fluid may be permitted 
to flow in until the discomfort is marked, when the tube is 
pinched and the fluid evacuated. In the absence of a double 
catheter, a single instrument may be used; the bladder is filled 
and the fluid is allowed to flow out, and the process is repeated 
until the bladder has been filled and emptied a number of times. 
This procedure, practised once or twice daily, gradually dis- 
tends a contracted bladder and diminishes its irritability. The 
irrigation fluid may be hot normal salt solution; boric acid, 
5ij-iv, to water, Oij ; or methyl-blue (pyoktanin), gr. xv, to 
water, Ojss, night and morning. If the urine contains pus, 
employ a two per cent, solution of ichthyol, flve or six times daily ; 
the strength may be gradually increased to five per cent, after 
subsidence of acute symptoms. The strength of the solution 
at the beginning should not exceed one-half of one per cent. 
S. D. Powell advocates irrigation of the bladder with a solution 
of carbolic acid i to 30, followed by irrigation with alcohol; 
subsequently a 2 per cent, solution of the carbolic acid is em- 
ployed. Protargol i to 10 per cent., mercurol 2 per cent., 
zynol 3 per cent, (zinc acetate and aluminol i to 4), are also 
highly extolled. Lutaud advocates throwing into the bladder, 



INFLAMMATIONS. 327 

after irrigation with a boric acid solution, four ounces of tepid 
water, to which is added a teaspoonful of the following emulsion : 

JJ . Iodoform , ,^ j 

Glycerin. , 3 x 

Aq. destil. , 5 v 

Tragacanth., gr.iv. M. 

This preparation should be introduced and permitted to 
remain. In necrotic and suppurative cases cleanliness is of 
prime importance. The bladder should be frequently irrigated. 
The frequent ichthyol irrigation is rapidly curative. The 
cavity of the bladder may be explored by dilating the urethra 
and introducing one of the vesical tubular specula used by 
Kelly. With a good light the cavity can be carefully inspected 
and applications, such as silver nitrate, gr. x-xxx, to aq. de- 
stillat., fSj, made directly to the affected area. In the use 
of these stronger applications, touching the affected or ulcerated 
points with the solution should be followed by irrigation with a 
salt solution. 

In subacute and chronic cystitis Clark introduces a vesical 
balloon of thin rubber. This balloon is connected with a thicker 





Fig. 279. — Double-current Catheter. 

rubber tube, provided with a cut-off valve. Before using, 
it is boiled in a boric acid solution, and its surface is coated over 
with a mixture of gelatin and ichthyol, ten per cent., or bis- 
muth and zinc, salicylic acid, or Aveak bichlorid. The mix- 
ture is melted and poured over the bag, which has been rolled 
in the shape of a suppository. With a slender pair of forceps 
the balloon is introduced through the speculum. It is then 
inflated by a bulb syringe, the number of bulb pressures re- 
quired to fill it having been previously determined. The balloon 
remains in situ twenty minutes. 

Guyon, in bad cases, advises that the bladder should be 
irrigated under anesthesia with a solution of boric acid or sub- 
limate, (i : 10,000) and cureted with a medium-sized curet. 
The finger in the vagina as a guide enables him to go over the 
base and sides, while the hand over the abdomen aids in reach- 
ing the anterior surface; lastly, the urethra is scraped, the 



328 GYNECOLOGY. 

irrigation is repeated, and a self-retaining catheter is intro- 
duced and retained some fifteen or twenty days. 

Camero reports twenty-nine cases thus treated, of which 
nineteen were successful. Le Clerc-Dauday follows cureting 
by irrigation with a solution of chlorid of iron, and later by 
instillation of a i per cent, solution of silver nitrate. In serious 
tubercular cases in which pain and tenesmus are very marked 
cystotomy may be employed. It places the bladder absolutely 
at rest. A sound or bougie is passed through the urethra and 
used to depress the anterior vaginal wall while an incision is 
made through the septum. The vaginal and vesical surfaces 
are united by sutures to prevent the opening from closing. 
This procedure deprives the patient of control of the bladder 
contents, and requires the provision of an apparatus or receptacle 
for the urine. 

With the removal of the gangrenous mass, the bladder 
should be irrigated with a boric acid solution (4 : 100) or a for- 
malin solution (i : 5000). A graduated irrigator is preferably 
employed, and not more than three or four ounces should be 
injected at one time. This may be pressed out, and the fluid 
again allowed to flow in, repeating this twenty times. The 
irrigation should be performed four times daily. It is sur- 
prising in these cases of extensive septic inflammation to note 
the subsequent power to retain the urine. 

355. Ureteritis is inflammation of the ureter, and may be 
acute or chronic. It generally begins in the mucous mem- 
brane, extending through the wall of the canal, so that the 
ureter presents the palpable sensation of a thick, rigid cord. 

Causes. — The disease, according to Mann, is produced by 
a number of causes: flrst, injuries during parturition; second, 
from previous disease of the bladder; third, gonorrhea; fourth, 
suppuration in the pelvis of the kidney; fifth, pelvic disease, 
such as pelvic peritonitis, cellulitis, and tumors ; sixth, abnormal 
conditions of the urine; seventh, tuberculosis, to which may 
be added an eighth — the passage of calculi. 

356. Acute ureteritis is often mistaken for intestinal colic, 
pain from renal strain, catarrhal appendicitis, or acute catarrhal 
salpingitis. The patient has a sudden attack of abdominal 
pain in which the distress is limited to, or more pronounced 
upon, one side, or but slight upon the other. The pain is in- 
termittent, with not infrequently severe paroxysms. General 
abdominal tenderness is probably absent, while there is notice- 
able tenderness upon deep palpation upon the affected side, 
which in the beginning is more marked near the pelvis of the 
kidney. The site of most marked tenderness may be situated 
at McBurney's point. As the inflammation subsides the pain 



INFLAMMATIONS. 329 

disappears, and may be recognized at a point an inch above 
Poupart's ligament. Originating in the back, it can not be 
differentiated in the early stage from colic occasioned by renal 
strain. When complicated by intestinal disorder, it may be 
recognized by its characteristic progress from above down- 
ward, the appearance of vesico-ureteral tenderness, and the 
urinary disturbance. The condition may terminate in recovery 
or may result in the chronic form. 

357. Chronic ureteritis is characterized by frequent desire 
to urinate, which is more marked while erect, especially when 
standing, and is not wholly relieved by retaining the recumbent 
position. The patient is obliged to arise from one to many 
times a night; the discharge may or may not be painful. Fre- 
quently, the desire to evacuate the urine will be imperative, 
and the urine will gush forth before she can secure privacy. 
In some cases she complains of bearing down, greatly increased 
by standing, which disappears after a few hours' rest in bed. 
Palpation may afford no sign, except a slightly thickened cord, 
or a rigid mass almost the size of the finger, pressure along 
which will cause a discharge of urine with such power as to 
drive it some distance from the urethral orifice. The necessity 
for a cystoscopic examination of the bladder will depend upon 
the severity of the attack; when attended with much pain, 
it should be made. An alteration of the vesical mucous mem- 
brane in and about the orifice of the ureter will be recognized. 

This alteration may vary from a slight eversion and gaping 
of the orifice to one in which the orifice is an oval opening upon 
the summit of a mound of angry looking mucous membrane. 
The mucous membrane in the immediate vicinity may be normal, 
but is generally red and injected, even roughened and eroded. 

The urea is said to be decreased upon the aft'ected side. 

The urine may be secured for examination by catheterizing 
the ureters or by the introduction of the Harris double catheter. 

Treatment. — General treatment consists in the careful regu- 
lation of the diet, from which should be excluded strawberries, 
asparagus, and stimulants ; tomatoes, onions, and cabbage should 
be used sparingly and with caution. The food should be largely 
albuminous, of which skimmed milk may often with advantage 
form its base. Large quantities of water, alkaline diuretics, 
or the alkaline waters are useful. In acute and subacute con- 
ditions the patient is best in bed. The nutrition should be 
maintained by general massage. 

Local applications are advantageously made to the infiamed 
orifice of the ureter and to the eroded surface about it. A 
solution of silver nitrate (gr. x-xxx to f5j) produces good 
results. It should be applied through a speculum directly to 



330 GYNECOLOGY. 

the affected surface, after which the bladder should be irrigated 
with a normal salt solution. 

When the inflammation of the canal is extensive, the dis- 
ease may be treated by irrigation through a ureteral catheter. 

In tuberculous disease, which is generally secondary to 
disease of the kidney, the affected kidney (the other having 
been demonstrated to be healthy) should be extirpated, and 
with it the ureter. 



INFLAMMATION OF THE CERVIX AND BODY OF THE UTERUS. 

358. Classification. — The classification of uterine inflamma- 
tion has been and still is a difficult and perplexing problem. 

Various views have been presented. The existence of in- 
flammation of the endometrium, except in acute conditions, 
has been denied. The so-called chronic inflammation is de- 
nominated catarrh and uterine congestion, and is frequently 
attributed to peri-uterine inflammation. This statement would 
seem a distinction without a difference, and results from failure 
to appreciate the varying character of inflammatory changes 
in different tissues. The continuous mucous membrane is 
exceedingly vulnerable to the possibilities of infection. The irri- 
tation thus produced results in the production of inflammation. 
Its violence and extent will depend upon the virulence of the 
poison and upon the resistance of the patient. It may vary 
from a slight inflammation involving the cervix only to one 
which extends to the entire uterine cavity, with inflltration 
of the submucous structures, becomes interstitial or parenchy- 
matous, not infrequently, in virulent attacks, passes through 
the wall to its surface and causes perimetritis. In our early 
classification we spoke of metritis, in the sense of inflammation 
of the entire organ ; when it is conflned to the lining membrane, 
it is called endometritis. When involvement of the deeper 
structures occurs it is known as parenchymatous or interstitial 
metritis, and as perimetritis if the peritoneum becomes involved. 
The latter condition is generally described as pelvic peritonitis, 
because, although inflammation can reach the peritoneum 
as described, it more frequently does so by the progress of 
the inflammation through the tubes, and the inflammation is 
much more extensive. 

The arrangement of the cervical mucous membrane renders 
it evident why inflammation may be conflned to the cervix, 
although in puerperal women it is very prone to extend to the 
body. 

The various classiflcations are based upon clinical phe- 
nomena, pathologic changes, and causal relations. The ideal 



INFLAMMATIONS. 331 

classification is that of Doderlein, into two divisions: first, 
inflammation produced through the influence of micro-organisms ; 
second, inflammation independent of their influence. The 
former is subdivided into: (a) septic and saprophytic; (6) gon- 
orrheal; (c) tubercular; (d) syphilitic; (e) diphtheric. The 
brevity of our knowledge of the influence of micro-organisms 
makes a careful dift'erentiation diflicult, but we are scarcely 
in a position to assert that there is any inflammation that is 
absolutely independent of bacterial production. My experience 
as a teacher has led me to discard the classification based upon 
the clinical phenomena, because it is diflicult to associate there- 
with the pathologic relations. For this reason I propose to 
present the simpler and more frequently employed classification 
into acute and chronic, the latter subdivided into cervical 
catarrh, or endocervicitis, endometritis, and metritis. Acute 
endometritis affects both body and cervix. The chronic in- 
flammation can be localized in the cervical mucous membrane. 
The classification of uterine diseases is still further complicated 
by the physiologic changes which occur in the uterus as a 
result of menstruation. Thus, the uterine mucosa undergoes 
a periodic hypertrophy and degeneration, and it is often diflicult 
to differentiate between the physiologic condition and early 
pathologic processes. 

359. Endocervicitis ; Chronic Cervical Catarrh. — Cervical en- 
dometritis is an inflammatory process which affects not only 
the cervical canal, but the entire cervix. The symptoms and 
appearance of the disease dift'er greatly in the unmarried or 
nulliparous and the multiparous woman, and it manifests itself 
as inflammation of the portio vaginalis or of the cervical canaL 
In the former, the connective tissue of the vaginal portion of 
the- cervix shows decided small-cell infiltration ; the blood-vessels, 
^especially the capillaries, become dilated and turgid with blood. 
^ Sometimes they become so distended as to form varicosities, 
resembling hemorrhoids. Immediately beneath the epithelium, 
the connective tissue is found rich in cells which later become 
converted into granular tissue. The squamous epithelium of 
the surface is in many places infiltrated with leukocytes, and 
it undergoes hypertrophic changes from the increased blood- 
supply. Numerous papilla are formed, which are covered Avith 
a single layer of epithelium, which permits the red color to show 
through and the surface to present the appearance of an erosion. 
(Fig. 280.) This condition is generally known as simple erosion, 
and it more usually involves the squamous epithelium of the 
vaginal portion of the cervix. When the external os has been 
lacerated, the lips will often be widely separated and gaping. 
The mucous membrane is everted and presents irregular granular 



332 GYNECOLOGY. 

patches which protrude beyond the os. Such a condition was 
formerly regarded as ulceration. Examination of a patch 
shows the apparently raw surface covered with epithelium. 
The increased blood-supply and the infiltration of the tissue 
with lymphoid cells causes the cervical lining to roll out of the 
OS and rest upon the cervix like a fungus. Such a reddened, 
everted surface is sometimes known as granular or papillary 
erosion. At first the glandular structure is not involved, but 
eventually hyperplasia of the glandular epithelium results 
and there is an increase in the number and size of the glands. 
(Fig. 281.) The latter condition is more limited to the super- 
ficial structure, which seems to be taken up with glandular tissue, 
to the almost complete exclusion of the connective. In the 





Fig. 280. — Simple Papillary Erosion Fig. 281. — Simple Papillary Erosion 

of the Cervix. with Enlarged Follicles. 

former, the glands enlarge and project through the structure 
of the cervix, sometimes even lifting up the squamous layer. 
The accompanying hyperplasia of the connective tissue may 
cause more or less constriction of the gland ducts, and in certain 
places they may be completely closed, thus resulting in the 
dilation of the glands and the formation of cysts. These cysts 
are known as retention cysts or ovules of Naboth. (Fig. 282.) 
They form nodular projections around the external os or can 
project deeply into the cervical tissue, projecting upon the 
vaginal surface at some distance from the external os. As the 
vaginal portion in the normal condition possesses no glands, it 
is evident these have been either extruded from the os with the 



INFLAMMATIONS. 333 

hypertrophied mucous membrane, or have pushed through 
the structure of the cervix in the manner already described, 
and may lead to an extensive cystic degeneration of its structure. 
Infection may result in the formation of abscesses, or the gradual 
distention may lead to rupture of the cyst, producing what is 
known as follicular erosion, in which the greater portion of or 
the entire cervix may be involved. The increased glandular 
secretion, mixed with the transudation from the eroded surface, 
produces a very profuse leukorrheal discharge. The protrud- 
ing structure often is so marked as to render its origin uncertain, 
but it evidently arises from the proliferation of the epithelial 
lining of the cervical glands. Chronic inflammation of the 




Fig. 282. — Chronic Endocervicitis. 
a. Dilated gland forming cyst of Naboth. h. Detachment of glandular epi- 
thelium after absorption of fluid. 

connective tissue occasionally causes such hyperplasia as to 
greatly increase the size of the cervix. In the nulliparous 
the cervix forms either a rounded mass, which increases the 
size of the cervix in all directions, or the latter may become 
so elongated as to produce a condition resembling prolapsus, 
and hence known as pseudoprolapsus. In previous laceration 
of the cervix only one lip may have undergone this hyperplasia, 
or both lips may be involved, when they will be widely everted 
and turned outward and backward, reminding one of the top 
of a celery stalk. The glands over such a surface are likely to 



334 GYNECOLOGY. 

become obstructed and produce retention cysts, which are 
recognized as firm, pea-hke masses beneath the finger. Occa- 
sionally such cysts form abscesses or rupture, and with the 
proliferating epithelium present an extensive raw surface which 
may be mistaken for carcinoma. A number of cysts in close 
approximation may become united through the absorption 
and breaking-down of the intervening septa and thus form 
one large cyst. Puncture of the cyst permits the escape of a 
large quantity of viscid fluid rich in corpuscles, with subse- 
quent contraction and obliteration of the cavity. 

From the discussion, it can be readily inferred that the 
inflammation involves all the structures of the cervix, the epithe- 
lium, the glands, and the connective tissue, and this varies in its 
form and manifestations according to the predominance of the 
structure involved. When the glands are extensively involved, 
the cervix presents what is known as cystic degeneration. The 
increase of connective tissue results in what Thomas has so aptly 
described as areolar hyperplasis or cervical sclerosis. 

360. Causes. — Inflammation of the cervix arises from exten- 
sion of inflammation from the body of the uterus, the vagina, 
and the vulva, as a result of excessive coition, laceration, in- 
juries during instrumental and digital examination and manipu- 
lation, and from puerperal and gonorrheal infection. The 
cylindrical lining of the cervix is particularly vulnerable to 
infection, especially after laceration, when exposed to friction 
against the walls of the vagina, and to injury during the act 
of coition or examination. It is rare to have inflammation 
of the body of the uterus without involvement of the cervix. 
The latter is prone to occur because the uterine discharges 
flow over the cervical mucous membrane and irritate it. Endo- 
cervicitis is particularly likely to be produced by congestion 
of the uterus in association with flexions, and especially retro- 
flexion. In retrodisplacements, separation of the lacerated 
surfaces is favored, and the delicate cervical mucous mem- 
brane is to a greater degree exposed. 

361. Symptoms. — The principal symptoms of cervical in- 
flammation are leukorrhea, pain in the back and loins, ag- 
gravated by exercise or standing, irregular menstruation, and 
sterility. Leukorrhea is the most important symptom. The 
normal secretion from these parts is insufficient to attract 
attention. When it is excessive, it becomes known as leu- 
korrhea, or, in popular language, the whites. A temporary 
discharge — a transparent leukorrhea, like white of egg — not 
infrequently occurs preceding and following the menstruation, 
due to temporary congestion. The secretion from the cervical 
glands is clear and viscid, resembling white of egg. It be- 



INFLA^QIATIOXS. 335 

comes white when mixed with m.ucus-corpuscles, and yellowish 
when pus-corpuscles are present. Not infrequently it is tinged 
with blood, which escapes from the delicate vessels of the newly 
formed vascular tissue. Pain is aggravated by walking, stand- 
ing, riding, or anything which increases the friction between 
the cervix and the vaginal walls. ^Menstruation is irregular 
and there is generally an increase in the quantity of the flow, 
probably produced by an extension of the inflammation to 
the endometrium. Sterility is often present. In the nulli- 
parous woman suffering from endometritis the cervical canal 
is filled by a plug of mucus, which may afford a bar to con- 
ception. In the muciparous woman the presence of cervical 
inflammation may render the woman less susceptible to preg- 
nancy, but it is not, however, considered an absolute obstacle 
to conception. 

362. Physical Signs. — The appearance and outline of the 
cervix differ in the nulliparous and in the multiparous woman. 
In the former it is puffy and large ; the os being soft and velvety. 
The patient will complain of pain when the cervix is moved 
or pressed. In the multipara the cervix is generally lacerated; 
its margins are soft, velvety, and eroded, or hard, presenting 
pea-like nodules, polypoid projections, cystic masses; or the 
OS may be gaping, so as to permit the introduction of the finger 
nearly to the internal os. The mucous membrane is irregular, 
not infrequently presenting longitudinal ridges. Digital exam- 
ination affords an idea as to the position and relation of the 
cervix, and as to its condition, whether lacerated or otherwise. 
The digital examination should be supplemented by the use 
of the speculum, the latter being used to confirm ^ suspicions 
which have been engendered by the digital examination. The 
Sims speculum is preferable, as it aft'ords less displacement to 
the parts and permits more thorough and complete inspection. 
In the nullipara the os will be filled with a plug of tenacious 
mucus surrounded by a patch of excoriated tissue, particularly 
upon the posterior lip, from which the outer layers of the epithe- 
lium have been desquamated. In the multipara a laceration 
will probably be seen. Its presence is often overlooked, be- 
cause the fissures are filled up with indurated cicatricial tissue. 
The use of tenacula to turn in the surfaces demonstrates its 
existence. The bluish-red ovula Xabothi may be readily seen 
as nodular projections upon the surface. 

363. Diagnosis. — Cervical catarrh is readily determined from 
vaginal inflammation by the use of the speculum. In the 
former a plug of mucus will fill up the cervical canal and pro- 
ject from it, being so viscid and tenacious that its removal 
is accomplished only with difficulty. To thoroughly cleanse 



336 GYNECOLOGY. 

the surface of mucus it may be necessary to use a curet. The 
mucus in the interior of the dilated glands should be removed 
by puncture and digital pressure. When the cervical dis- 
charge is insufficient to render it visible, Schultze's method 
may be employed. He gives the patient a vaginal douche, 
introduces a speculum, thoroughly cleanses the surface, and 
places a tampon soaked with a solution of tannin against the 
external os. This applied at night and removed through a 
speculum the following morning, the character and quantity 
of the discharge from the cervix can be noted. The differen- 
tiation between endocervicitis and endometritis is still more 
difficult. In many cases, indeed, we may not be able to say 
definitely that a cervical catarrh is not associated with more 
or less inflammation of the endometrium. The enlargement 
and thickening of the cervix demonstrate that it is the seat of 
inflammation. It is sometimes difficult to differentiate be- 
tween inflammation and malignant disease of the cervix. In 
the former the hypertrophy is more general and uniform, the 
tissues are more or less firm, but not hard, and show no in- 
clination to friability. In malignant disease the cervix may 
at points be hard and indurated from the presence of an in- 
filtrate which is more or less localized. An excavated ulcer 
may be present, covered with friable, easily broken-down tissue, 
which will crumble and become detached under the finger, 
while the base is hard and resisting. Hemorrhage and a pro- 
fuse, foul-smelling discharge are prominent symptoms. When 
the condition is such as to leave one in doubt, a test excision 
of the tissue should be made and subjected to microscopic 
investigation. 

364. Prognosis. — The curability of the condition is de- 
pendent upon the general health of the patient, the duration 
of the disease, and the extent of involvement. Not infre- 
quently it will be found that these patients have passed through 
the hands of a number of physicians, and, therefore, extreme 
care must be exercised as to the prognosis. The result is less 
favorable when there is a large amount of secretion and ap- 
parently but little glandular degeneration. 

365. Treatment. — First, constitutional: The patient should 
be encouraged to take outdoor exercise, and not infrequently 
change of air will prove of decided value. Tonics, such as 
quinin, iron, strychnin, arsenic, and the bitter tonics, will be 
of advantage. Indigestion should be corrected, regular action 
of the bowels secured, and sexual rest directed. 

Second, local treatment: In the nullipara, it is advisable 
to give hot vaginal douches through a fountain syringe under 
moderate pressure for ten to fifteen minutes each night, having 



INFLAMMATIONS. 



337 




Fig. 283. — Lines of Inicision for Contracted or 
Pinhole Os. 



the patient preferably in the recumbent position. Doubt- 
less in some cases the hot water thrown with force from a bulb 
syringe against the cervix will have a more marked modifying 
influence upon the hy- 
perplastic process and, 
therefore, it should sup- 
plant the fountain syr- 
inge. The temperature 
of the water should be 
from 110° to 115"^ F., 
and the patient should 
be advised to remain 
in bed following the 
douche. Astringents 
can be added, such as 
a solution of zinc sul- 
phate (i to 2 drams to 
the pint) or corrosive 
sublimate (i : 4000). 
The OS, when narrow^ 
and contracted so that 
the drainage is ineffec- 
tive, should be notched bilaterally with scissors, to permit the 
escape of the mucus. The lips should be trimmed, making a 
funnel-shaped opening (Figs. 283 and 284). When the secre- 
tion continues, local ap- 
plications, such as tinc- 
ture of iodin or carbolic 
acid, a saturated solu- 
tion of iodin crystals in 
carbolic acid. 95 per 
cent., can be employed; 
the former in mild, the 
latter in more severe 
cases. Heywood Smith 
advises acid nitrate of 
mercury ; De Sinety, 
chromic acid. In mak- 
ing an application, the 
mucus should first be 
removed from the canal 
with a cotton-wrapped 
applicator or a blunt 
curet. This step is im- 
portant to prevent the application being coagulated by the 
mucus without reaching the affected surface. After the ap- 
22 




Fig. 284. — Union of Vaginal and Cervical 
Mucous Membranes. 



338 GYNECOLOGY. 

plication any surplus fluid should be removed, and a tampon 
of cotton or of gauze saturated with glycerin should be placed 
beneath the cervix. A 25 per cent, solution of ichthyol in 
glycerin, or ichthyol in lanolin, of the same strength, may 
be applied to the cervical canal with a cotton-wrapped probe, 
or a small pledget of gauze or cotton anointed with it may 
be carried into the dilated cervix, or a tampon medicated with 
it may be applied to the eroded cervix. Ichthyol is advisable 
because of its germicidal action. The application of such a 
tampon will not infrequently result in the desquamation of 
an epithelial cast, followed by a regeneration of the epithelium 
and restoration of a healthy appearance of the cervix. The 
application of a saturated solution of iodoform in ether is ad- 
vised. Ether stimulates contraction of the glands and forces 
out the secretion, while the iodoform remaining acts as an 
antiseptic. In the multipara endocervicitis is not infrequently 
complicated by retroflexion, subinvolution, or laceration of 
the cervix. The first consideration should be to relieve con- 
gestion by hot astringents, antiseptic douches, or the use of 
glycerin tampons. The displacement should be corrected 
and the organ should be maintained in a proper position by a 
tampon or by the use of the pessary. When the cervical mucous 
membrane is much everted and the lips are widely separated 
by laceration of the cervix, the relief of the engorgement and 
congestion can be overcome by the employment of Emmet's 
operation. Frequently, the uterine congestion may be decreased 
by local depletion through scarifying or puncturing the cervix. 
This procedure is of special value where a number of glands 
■of Naboth have become obstructed and have formed retention 
cysts. Puncturing the cysts and introducing tincture of iodin 
or carbolic acid produces a sufficient amount of inflammation 
to obliterate the cavity and remove the pressure. In very 
obstinately chronic cases destruction of the diseased glandular 
tissue is imperative. It may be accomplished by the use of 
the Paquelin thermocautery or by various caustics. Skoldberg 
recommends zinc alum sticks, which are made by running 
together into molds equal parts of zinc sulphate and alum 
sulphate, forming a small stick, which is carried into the cervix 
and retained by a plug of wadding in the vagina, which also 
receives the discharge. Silver nitrate in solid stick was formerly 
much used for this purpose. The latter method of treatment 
is required only in exceedingly severe cases, and its application 
should be extremely limited. It cures by destruction of the 
mucous membrane and glandular structure, substituting for 
them cicatricial tissue. It should not be used where there 
is danger of the cervical canal becoming so contracted as to 



IXFLAMMATIONS. 339 

interfere with drainage from the uterine cavity. Colpe, finding 
that an inflammation of the cervix did not yield to the use of 
astringents and caustics, examined the secretion and found 
present mycotic spores, after which he used lactic and salicylic 
acids, with immediate relief. 

Electricity has its advocates — the negative pole is introduced 
into the cervix, while the positive pole is placed upon the abdo- 
men. It is questionable, however, whether this plan of treat- 
ment has any advantage over other caustic measures. The use 
of the sharp curet not only removes the glands from the cervical 
canal, but, as advocated by Thomas, scrapes away the arbor vit^ 
from the internal to the external os. This measure not infre- 
quently has to be repeated a second or even a third time before 
relief is complete. When there is very marked eversion, or an 
eroded, deeply fissured surface, Schroder's operation should be 
performed. This consists in the formation of a single flap in 
each lip. The method of procedure has been described. (Sec- 
tion 268.) Martin removes a larger amount of the cervix, and 
combines amputation with excision. He splits the cervix into 
two lips, cuts through the cervical mucous membrane on the 
posterior lip above the diseased portion, then removes as much 
of the lip as is necessary, and stitches it. The anterior lip is 
treated in the same way. 

366. Acute Metritis and Endometritis.— In acute inflamma- 
tion the pathologic changes are not confined to the endometrium, 
but rapidly involve the entire organ. In the non-puerperal 
uterus they are excited by infection from gonorrhea, or follow 
trauma, induced by exploratory operative procedures, or result 
from exacerbations of the chronic state. The non-puerperal 
cases are rare and scarcely ever fatal or sufficiently threatening 
to require hysterectomy. Such an inflammation is generally 
brought on by an infection which has occurred during parturition 
or abortion, and, consequently, is more an obstetric than a 
gynecologic infection. 

Infection is favored: 

1. By protracted labor during which the tissues have been 
subjected to bruising or laceration. 

2. Through want of skill or of cleanliness in the practice of 
manual or instrumental procedures. 

3. From the retention of clots or of portions of placenta or 
■decidua after labor or abortion. 

4. By the presence of septic germs in the genital canal prior 
to the interruption of gestation or by their introduction during 
the process of delivery or in the subsequent convalescence. 

367. Pathologic Alterations. — The infection is originally im- 
planted in the degenerated mucous membrane, the blood-clots 



340 GYNECOLOGY. 

of the uterine sinuses, the site of the placenta, or in retained 
portions of the placenta or decidua. Intense hyperemia results, 
with alterations in all the tissue elements. The gland lumina 
are dilated by the increased secretion and proliferation of the 
glandular epithelium. Inflammatory infiltration takes place 
into the tissues with subsequent degeneration and destruction 
of the cellular elements. The mucous membrane becomes 
greatly swollen and edematous. The epithelium is found 
granular and desquamating. The blood-vessels become engorged 
and thrombosed. Inflammatory material is poured into the 
cellular tissue, which may terminate in abscess formation, either 
in the wall or sinuses or both. 

These pus pockets, at first small and localized, increase in 
size, the intervening walls break down, and an abscess of con- 
siderable size may form, which may rupture into the uterine 
cavity and thus terminate favorably, or a large portion of the 
uterus may become gangrenous, causing serious detriment to 
the health, and even loss of life. In an autopsy upon a patient 
who died under my care in the Philadelphia Hospital, the entire 
fundus was found to have been completely destroyed. 

368. Varieties and their Source. — The symptoms will be 
found to depend upon the character of the infection, and this 
can be divided into sapremic and septicemic. Sapremic infec- 
tion is induced by the action of the saprophytes upon retained 
blood-clots and portions of the decidua or placenta, which 
cause decomposition of the retained tissue, with the subsequent 
absorption of the decomposing products. Decomposed material, 
when undisturbed, presents a soil favorable for the development 
of septic infection. The latter condition, however, occurs much 
more frequently as a primary disorder from the entrance of 
pathogenic germs through fractures of the mucous membrane 
of the uterine body, cervix, vagina, or vulva. We have already 
asserted that inert pathogenic germs which inhabit the vagina 
can, by changed conditions, be stimulated into activity, but 
they are, however, more frequently introduced from without, 
through failure of the physician or nurse to observe proper 
antiseptic or aseptic precautions. 

369. Symptoms. — Sapremia occurs in from three or four to 
ten days subsequent to delivery. The onset of the trouble is 
rather sudden, and is manifested by elevated temperature and 
repeated rigors. The patient may have severe chills, daily 
temperature varying from 102° to 105° F. The lochial dis- 
charge may be absent or, if present, is exceedingly foul. The 
patient generally manifests but little tenderness upon pressure. 
Manipulation over the uterus may be followed by contraction 
and the expulsion of a large offensive mass, after which the 



INFLAMMATIONS. 341 

patient will improve, or she may have quite profuse bleeding. 
Digital examination discloses the presence of retained masses 
and affords evidence of their decomposition. The onset of 
septicemia is more insidious, but the symptoms occur earlier. 
The reaction induced by septicemia will depend upon the condi- 
tion of the patient, the time of the infection, and the virulence 
of the infective poison. As early as the second or third day, 
not infrequently upon the first, the patient will exhibit an 
elevation of temperature, which gradually increases. She 
suffers from pain or tenderness in the lower abdomen, which 
may be so marked as to confine her to the dorsal decubitus, 
with her limbs flexed and unable to exercise the slightest muscular 
action, because of pain. Not infrequently, the bladder becomes 
greatly distended; the pulse is rapid, varying from no to 140; 
respirations frequent, and the temperature displays a range 
from 101° to 107° F. The lochial discharge is arrested or free, 
and may be mucous, muco-purulent, ichorous, or sanguinolent. 
It may have a stale, sickening smell or be almost free from odor. 
The cervix and vagina, upon inspection, may appear normal 
or highly inflamed, swollen and covered with glairy mucus, 
or exhibit patches of diphtheric exudate. The uterus is likely 
to be smooth, swollen, and exceedingly tender to pressure. 
The cervix will appear lacerated and boggy. The entire organ 
will be found enlarged, edematous, and flabby. When the 
inflammation is confined to the uterus, the organ will be tender 
and enlarged, but not so sensitive as to preclude palpation. 
If, however, the peritoneal coat is involved, the pain and tender- 
ness will be very acute; the limbs are drawn up to protect the 
abdomen from pressure of the clothing and to relieve the traction 
upon the abdominal wall. The progress of the disease will 
depend upon the virulence of the poison and the resistance 
of the patient. In the sapremic condition the source of origin 
of the disease may be expelled and the patiently rapidly pro- 
gress toward recovery. A patient suft'ering from septicemia 
may be so fortunate as to secure immunity against its further 
progress, and slowly recover. The disease may become localized 
and a pus collection be spontaneously or artificially evacuated, 
or the general system may become so infected that, notwith- 
standing every therapeutic procedure, the patient succumbs. 
An unfavorable prognosis is indicated by a persistent high 
temperature, a pulse-rate continuously above 130, and the 
absence of localized foci. If the serious symptoms subside 
and the general condition of the patient improves, but a rapid 
pulse-rate continues, associated with an evening temperature 
of 100° F. or over, the patient should not be regarded as out 
of danger. This disorder was formerly known as puerperal 



342 GYNECOLOGY. 

fever and supposed to be due to some obscure poison charac- 
teristic of the condition. The investigations of Semmelweis 
and others demonstrated that it was analogous to surgical 
fever and due to a similar cause. The disorder is hydra -headed 
in its manifestations and makes its invasion by one of three 
routes: Through the continuous mucous membrane of the 
body of the uterus and Fallopian tubes, to the peritoneum; 
through the blood-vessels or lymphatics. Thus we may have 
inflammation of the structure of the uterus, the Fallopian 
tubes, the ovaries, the pelvic cellular tissue or the pelvic perito- 
neum, or even all combined. Any of the veins of the body 
may become involved in the septic phlebitis, but the condition 
occurs most frequently in those of the lower extremities, caus- 
ing the condition formerly known as milk leg, which we now 
recognize to be an infective phlebitis. It may manifest itself 
also by a severe lymphangitis. The disease may rapidly in- 
volve the general system, giving rise to profound symptoms 
of septicemia without any special localization. 

370. Diagnosis. — The early differentiation between sap- 
remia and septicemia is very important. The former, being 
associated with retained decomposing products, manifests 
itself several days after delivery. Symptoms develop suddenly 
in a patient who seemed to be undergoing a normal convales- 
cence. The lochial discharge, where present, is exceedingly 
offensive. A digital examination discloses a clot, a portion 
of placenta or a portion of decomposing membrane, within 
the uterine cavity. These products, when removed, have a 
very offensive odor, and with their disappearance the symptoms 
rapidly subside. In septicemia the symptoms occur more 
insidiously, and at an earlier date following delivery, unless, 
however, the infection should have been implanted late. The 
occurrence of elevation of temperature following a delivery 
should be regarded as a danger-signal, which should cause 
the attendant to make a careful investigation of the history 
of the case, together with a judicious interrogation of the phys- 
ical signs. The condition of the breasts should be ascertained, 
for not infrequently women have a high temperature con- 
comitant with the establishment of lactation. The breasts 
become greatly distended, caked, and hard. The temperature 
of the patient reaches 105° F. or over. Not infrequently, 
the nipples may be the source of infection, which may lead to 
the occurrence of a mammary abscess. Typhoid fever and 
malaria are frequently mistaken for sepsis and vice versa. The 
possibility of these conditions should be excluded by a careful 
examination of the blood; finding in malaria the plasmodium 
and in typhoid fever the securing of a positive Widal reaction 



INFLAMMATIONS. 343 

and the examination of the urine, are considered sufficient 
evidence to estabhsh the diagnosis. Furthermore, the typhoid 
bacillus may be found in the urine and also occasionally in 
the .blood. A digital examination excludes sapremia when 
it reveals the walls of the uterine cavity smooth and free from 
any decomposing products. Intoxication from morbid prod- 
ucts in the intestinal tract may sometimes closely simulate 
septicemia. It was quite recently my privilege to see 
with two young doctors, a young woman who was suffering 
from a very high temperature with some abdominal distention, 
in whom there were no signs of any localization of sepsis. The 
patient had been confined a week previous to the manifestation 
of symptoms. Examination disclosed the uterine cavity free 
from any decomposing material, and absence of tenderness 
over the uterus. The woman had had some fifteen foul-smelling 
stools during the last twenty-four hours. It was her first con- 
finement, and there was a history of her having undergone a 
curetment some three years before. She had been very care- 
fully managed during her confinement, w4th every aseptic 
precaution, and had been cared for by a well -trained nurse. 
The inference of the attendants was that she had had some 
local accumulation in a tube, prior to her confinement, from 
which this infection had developed. But as I found the uterus 
free from any tenderness or undue enlargement, no sign of in- 
fection in the vagina, and she had what seemed to me no tender- 
ness or swelling about either tube or ovary, I reasoned, there- 
fore, that if such local cause had existed, it should still show 
evidence of its presence, and in view of the very evident in- 
testinal disturbance, I ascribed the symptoms to an intestinal 
infection, and suggested measures for its correction. The 
rapid subsidence of the symptoms and recovery of the patient 
confirmed the diagnosis. 

Having reached a diagnosis in septicemia, by exclusion, 
it is then desirable to recognize and treat the local manifes- 
tations promptly. These we determine by the size and evidence 
of laceration of the uterus, the existence of patches of diphtheric 
exudation in the vagina or uterus, the possible form and prog- 
ress of the infection. Aletritis will be indicated by a large, 
swollen, more or less tender and boggy uterus; perimetritis or 
pelvic peritonitis by extreme tenderness in the lower portion 
of the abdomen, pain and anxiety of the patient, with a fre- 
quent, rapid, wiry pulse, and high, sometimes low, and even 
subnormal, temperature; the latter symptoms, moreover, rather 
increasing the danger. Phlebitis will be recognized by tender- 
ness over the femoral and saphenous veins, as these are the 
ones in which the disease most frequently manifests itself. 



344 GYNECOLOGY. 

Lymphangitis is often indicated by the existence of inflammation 
of the cellular tissue and by pain and tenderness over the lumbar 
or inguinal regions. 

371. Prognosis. — Sapremia is a condition which usually 
terminates favorably. The removal of the putrid products 
soon results in the subsidence of the constitutional intoxication. 
It should not be forgotten, however, that the putrid material 
affords a favorable soil for the development and propagation 
of septic germs, so that when a patient comes under obser- 
vation she may have been subjected to mixed infection. Under 
proper management, this condition generally terminates in 
recovery. Septicemia is an exceedingly dangerous disease; 
its manifestations are so various that often when the patient 
survives she may be in a condition which cripples her for life 
and at the expense of serious sacrifice of important organs. 
The condition demands the most careful scrutiny of the prog- 
ress of the disease, with the resort to radical procedure when 
it is manifest that local foci are continuing its propagation. 

372. Treatment. — Prophylaxis is the most important treat- 
ment, but is so closely associated with the work of the obstet- 
rician that we will not consider it. A woman who develops 
symptoms leading one to suspect the occurrence of a septic 
process should at once be subjected to careful investigation. 
This careful scrutiny is advised in order to eliminate the possi- 
bility of other conditions being confounded with sepsis. Finally, 
a pelvic exploration should be made, and all decomposing 
products, such as blood-clots, portions of placenta, or remnants 
of decidua, should be removed. The patient should be placed 
across the bed; if the abdomen is tender, an anesthetic should 
be given, and two fingers introduced into the uterus, which, 
with the hand over the abdomen, will permit the entire uterine 
cavity and wall to be thoroughly explored and all products 
and debris removed. The procedure not only removes the 
debris and contents of the uterus, but favors the pressing out 
of infected clots from the blood-vessels and uterine sinuses. 
This manipulation should be followed by intrauterine douches 
of sterile normal salt solution, or, better still, a i per cent, 
saline solution, made up of 2 J grains sodium bicarbonate to 
7 J grains of sodium chlorid to the 1000, or formalin solution 
I : 1500 : 1000, or sublimate solution i : 3000. When the uterine 
cavity is clear of decomposing masses and other causes are 
excluded, we are justified in accepting the diagnosis of septic 
infection, as contradistinguished from putrid intoxication. 
In septicemia, intra -uterine manipulation often will be unpro- 
ductive of any favorable result. The micro-organisms have 
already penetrated beyond the reach of any local measures. 



INFLAMMATIONS. 345 

Curetment, by affording fresh avenues for infection, is harm- 
ful. The uterine cavity should be irrigated through a double- 
current tube three, four, or more times daily with a hot i per 
cent, saline solution, or solutions of formalin or bichlorid. The 
latter solution (i : 3000) should be followed with normal salt 
solution to avoid the danger of mercuric poisoning. 

The removal of decomposing products, irrigation of the 
uterus, and the internal administration of salines in sapremia, 
or putrid intoxication, usually establishes early convalescence. 
Not infrequently, however, there will be a marked rise of tem- 
perature after such a procedure, but it soon subsides. Sepsis, 
on the other hand, is caused by micro-organisms, which have 
entered the blood, and kill, not so much by their presence, as 
by the toxins or poisons which they generate. Researches 
have seemed to demonstrate that these toxins, obtained from 
pure cultures of the organisms and injected into the circulation 
of some of the lower animals, soon generate an antitoxin which 
acts as an antidote to the original poison. My early experience 
in the treatnient of sepsis by the administration of the anti- 
streptococcic serum was such as to lead me to place greater 
reliance upon its efficacy in affording prompt immunity than 
the later experience of myself and colleagues would seem to 
justify. In severe cases as much as ten cubic centimeters 
(two and a half drams) in twenty-four hours should be employed. 
In less severe cases smaller doses, three to six cubic centimeters, 
can be employed. The dose should be administered daily 
until the abnormal symptoms subside. The advocates of the 
employment of serum therapy in the treatment of puerperal 
sepsis are doubtless correct in their demand that the serum 
must be fresh. The want of success may have been due to 
this cause, as many have employed the imported serum of 
Marmorek. A requisite to accuracy is the careful bacterial 
investigation of the secretions, for it would not be reasonable 
to expect a satisfactory result by the employment of anti- 
streptococcic serum in a staphylococcic infection. To be most 
effective, it is most important that the serum should be ad- 
ministered early and in good dose. The strength of the patient, 
and her consequent ability to fight the disease, should be main- 
tained by the administration of supporting remedies, by a 
nutritious, easily digested diet, and by the judicious use of 
stimulants. 

Quinin may be given in suppository (gr. v-x), three or 
four times daily; strychnin, atropin, tincture of digitalis, digitalin 
or adrenalin chlorid solution (i : 1000) should be administered 
hypodermically, as the indications demand. Action of the 
bowels should be secured by the proper use of salines, which 



346 GYNECOLOGY. 

facilitates the elimination of the infective products, though 
care should be exercised to avoid undue depletion. 

Intravenous Injections. — The intravenous injection of normal 
salt solution has been of great service to the surgeon in over- 
coming shock, and in carrying patients over a critical condition. 
It has been demonstrated, also, that this procedure is service- 
able in low septic conditions by increasing the volume of the 
blood, thus diluting toxic material, promoting secretion, and 
the consequent elimination of poisonous products. The com- 
bination of chlorid of sodium with bicarbonate of sodium, 
making a i per cent, saline solution which should be in the 
proportion of 7^ parts of the chlorid of sodium to 2^ parts of 
bicarbonate of sodium, has proved especially efficacious in 
septic conditions, as it increased the phagocytes and the con- 
sequent ability of the patient to resist the progress of the in- 
fection. 

The brilliant results achieved by Professor Baccelli, in 
1889, in the treatment of pernicious malaria, by the intra- 
venous injection of hydrochlorid of quinin, has directed the 
attention of the profession to the intravenous injection of 
germicides. Baccelli later instituted the intravenous injection 
of corrosive sublimate in the treatment of syphilis, after the 
administration of mercury by other methods had failed. His 
experiments on the lower animals demonstrated the fact that 
albuminate of mercury, which was first formed, was redissolved 
in an excess of albumin. 

As it is known that the micro-organisms enter the blood, 
the introduction of germicidal agents into this fluid to render 
it an unfavorable soil for their multiplication is a plan 
which naturally appeals to the scientific mind. The difficulty 
has been to secure some agent which shall prove destructive 
to the specific germ in the hemal circulation, without inducing 
degenerative changes in the circulatory fluid. Carbolic acid, 
sublimate, and formalin have all been recommended as suit- 
able agents for this purpose. In a recent case in which the 
conditions were such as to make it evident that death was 
imminent, unless the poison could be arrested, I injected J of 
a grain of sublimate in five hundred centimeters of normal 
salt solution. The patient the following day developed an 
infarct which cut off the circulation in the end of the nose, and 
she died at the end of forty-eight hours. As air, however, 
had entered, due to the faulty apparatus employed, it is not 
justifiable to condemn the bichlorid as the cause. Formalin 
has been especially commended of late, particularly by Barrows, 
of New York, and Maguire, of London. The latter, in his 
experiments, has injected solutions as strong as i : 500 into 



INFLAMMATIONS. 347 

himself. This was followed by hematuria, albuminuria, cramp- 
like pains, and faintness. I have applied gauze, wet with 
formalin solution (i : 1500-2000), to the peritoneum, w4th com- 
plete destruction of the endothelial covering of the involved 
surface, so that I should regard the injections of solutions of 
formalin, therefore, under i : 5000, as extremely dangerous, 
and as it has been claimed that it is germicidal in solutions 
of I : 200,000, a weaker solution still would seem preferable. 
As the simple injection of water into the blood-vessels causes 
degenerative changes in the blood-corpuscles, it would seem 
much wiser that these injections should be made in combina- 
tion with normal salt solution. In cases, then, in which it is 
evident that the patient will succumb to the disease unless 
it can be arrested, w^e should feel justified in proceeding to 
extreme measures with the hope of affording relief; and with 
our present knowledge of conditions, I should favor the formalin 
in combination with a normal salt solution as being the least 
deleterious of the agents we can employ. I w^ould advise that 
it be given in solution of i : 10,000. 

Localization of infection may result in abscess formation 
in the uterine wall, in the pelvic cellular tissue, in the tube, 
in the ovaries, or in multiple abscesses in various portions 
of the body. The manifestation of such a local collection 
should be deemed an indication for prompt surgical inter- 
ference. The treatment necessarily must depend upon the 
site and extent of the lesion. If an exudate or inflammatory 
collection can be reached by a vaginal incision, through which 
the contents of the cavity can be evacuated, its sac enucleated 
and removed, or the cellular tissue opened up and drained, 
more serious destruction of tissue can often be avoided. Where 
the uterus remains large and extremely tender, or presents 
indications of localized peritonitis, and the condition of the 
patient will permit, the abdomen should be opened and hysterec- 
tomy performed. The excision of a section of an infected 
vein has been successfully performed, but one must be satis- 
fied that the condition is not diffuse before resorting to such 
a recourse. 

When the temperature is elevated, skin hot and dry, with 
tympanites and repeated vomiting, the most effective plan of 
treatment is to irrigate the stomach with hot normal salt solu- 
tion, followed by intercolonic irrigation. The latter should 
be continued over several hours, or a quart of normal salt solu- 
tion should be injected into the bowel every hour. The admin- 
istration of large" quantities of salt solution promotes elim- 
ination. The tongue and skin become moist, the secretion 
of urine increased, the pulse increases in volume, and the tem- 
perature subsides. 



348 



GYNECOLOGY. 



373. Chronic endometritis is an inflammation of the mucous 
membrane of the body of the uterus. It rarely, if ever, is 
the consequence of acute endometritis, but more frequently 
follows subacute processes and long-continued hyperemia. 
It is divided by Ruge into glandular, interstitial, and mixed, 
according to the structure of the mucous membrane most 
extensively involved. In all varieties of inflammation the 
entire structure of the membrane is necessarily more or less 
affected. With thickening of the mucous membrane the glands 
become elongated, dilated, bent, and tortuous. Cells become 
swollen and proliferated, resembling those of the decidua. 











Fig, 285. — Interstitial Endometritis. 
a. Free uterine surface, b, b, b. Hyperplasia of connective tissue. c,c,c,c. 
Obliteration of glands, d. Choking of gland from increase of fibrous tis- 
sue, e, e. Glands occluded and somewhat dilated. 



The vessels of the deeper portion of the mucosa are dilated 
and in a state of congestion. The mucous membrane is not 
infrequently several times its normal thickness, soft, spongy, 
and easily scraped away. The surface presents vegetations 
or growths, which, according to De Sinety, are of three forms. 
In one, the tissue consists of dilated blood-vessels; in the second, 
of dilated, hypertrophied glands (Fig. 287); in the third, of 
embryonic tissue containing but few blood-vessels and only 
traces of glands. With these conditions are associated three 
kinds of discharge — sanguinolent, leukorrheal, and muco-puru- 
lent. As a result of the changes in the mucous membrane. 



INFLAMMATIONS. 



349 



not infrequently portions project as polypoid masses, which 
consist of either glandular or vascular structure (Fig. 288). 
In this condition the mucous membrane is thickened and granu- 
lar in appearance, and the state has been called villous de- 
generation, or endometritis fungosa. With cell proliferation 
in its connective tissue and the subsequent contraction of the 
gland, its structure is compressed and obliterated, so that 
the surface is almost free from glands. Or, again, the orifices 
of the glands' ducts in places become occluded and cysts result. 
The hyperplasia of the uterine mucosa in some cases results 
in the desquamation of the epithelial layers at each menstrual 
period. This desquamation may take place in the formation 







h\^ 




Fig. 286. — Hypertrophic Glandular Endometritis, showing Increase in Size 

and Numbers of Glands. 

a, a. Glands dilated and containing secretion, h. Infiltration of leukocytes. 

of shreds or in a complete cast of the uterus, in which the orifices 
of the Fallopian tubes and the internal os are recognized. This 
condition is known as exfoliative endometritis, membranous dys- 
menorrhea, or, probably better, menstrual decidua. (Fig. 289.) 
374. Symptoms. — The disease arises after abortion or labor, 
as a result of an attack of uterine inflammation, or an attack 
of gonorrhea. Occasionally, it may begin insidiously and 
without any sign of a cause. It occurs more frequently in 
the muciparous, and is more common in the later menstrual 
life. Nullipara are not exempt; even virgins are sometimes 
affected — a condition known as virginal endometritis. This 



350 



GYNECOLOGY. 



especially occurs in narrowing or stenosis of the external os. 
A form of the disease occurs subsequent to the climacteric, 
when it is known as senile endometritis. Endometritis is 
characterized by the following symptoms: leukorrhea and 




V(,K?>15A.N\.HM( 



Fig. 287. — Hypertrophic Glandular Endometritis. Vertical Section through 

the Mucous Membrane. 
a. Blood-vessel distended with blood-cells, b. Gland penetrating muscular wall. 



menorrhagia. The discharge from the body of the uterus 
is less viscid than that from the cervix. It may be clear, but 
more generally is mucopurulent; occasionally it is tinged with 
blood, so that the patient imagines herself continuously un- 



INFLAMMATIONS. 351 

well. The discharge flows freely or there is an apparent ac- 
cumulation. Retention of the discharge and its evacuation 
in considerable quantity occur when endometritis is complicated 
by retrodisplacements or when the os is small. The discharge 
may have an offensive odor and be so irritating as to give rise 
to extensive excoriation of the vulva. Excessive menstrual 
flow, or menorrhagia, may or may not be present. Occasionally, 
it will be so profuse as to occasion a suspicion of malignant 
disease and cause a profound anemia. The resulting loss of 
vasomotor tonus results in increased tendency to hemorrhage. 
Dysmenorrhea, or painful menstruation, is not so common 
as in disease of the appendages or in chronic metritis. It is 
especially marked when accompanied by the discharge of a 






'%-'li>- 



^1^1%? 











Fig. 288. — Polypoid Classes Associated with Chronic Endometritis. 
a. Glands greatly dilated with destruction of the intervening septum. 

menstrual decidua. The influence of endometritis upon con- 
ception is not fully determined, but the increased frequency 
with which women become pregnant subsequent to a curet- 
ment renders it evident that it has a restraining influence upon 
the occurrence of conception. Endometritis is a prolific cause 
for abortion. 

375. Diagnosis. — The existence of leukorrhea or of irregular 
and profuse menstruation, associated with enlargement of the 
uterus for which no explanation external to the uterus can be 
found, justifies the suspicion of endometritis. The histor}^ of 
abortion, or prolonged convalescence subsequent to labor, con- 



352 



GYNECOLOGY. 



firms the suspicion. The use of the curet is of incalculable 
advantage in determining the diagnosis. Portions removed 
with the curet will show small-cell infiltration of the entire 
glandular tissue, without glandular hyperplasia, or marked 
hyperplasia of glands with proliferation of the glandular epithe- 
lium. The epithelial cells become enlarged and granular, lose 
their cylindrical shape and resemble the decidual cell. Endo- 
metritis, when uninterrupted, extends to the deeper structures, 
producing metritis. It predisposes to malignant change. When 
permitted to pursue an undisturbed, course, it can involve the 
peri-uterine covering. Deposits occur in the cellular tissue 




Fig. 289. — -Membranous Dysmenorrhea. 



about the ovary or around the orifice of the Fallopian tube, or 
the disease involves the pelvic peritoneum. Neglected cases 
result in cellulitis, salpingitis, ovaritis, peritonitis, the for- 
mation of abscesses, the destruction of tissue in the organs, 
and not infrequently, alas, in loss of life! Senile endometritis 
is associated with retention of secretion which decomposes, 
producing an exceedingly offensive odor, and arouses the sus- 
picion of malignant disease (Dunning). The examination of 
such a uterus reveals its walls thinned; the mucous membrane 
consisting of a thin layer of connective tissue covered with a 
single layer of flattened epithelial cells. 



INFLAMMATIONS. 353 

376. Treatment. — Constitutional treatment is of marked 
value, and will be discussed with chronic metritis. Prophylaxis 
will require rigid asepsis during labor or abortion, as well as 
in making gynecologic examination. A rise of temperature or 
the suspicion of the retention of a portion of placental debris 
should be considered as indicating the necessity for thorough 
use of the curet, free irrigation, and, in many cases, gauze pack- 
ing. Laceration of the cervix or of the pelvic floor should 
have early repair. All suspicious discharges must be removed 
by treating the cause. Before the third or fourth day a 
gonorrheal endometritis is best treated by frequent irrigation 
with antiseptic solutions, such as permanganate of potash 
(i : 3000-2000), mercurol (1-2 per cent.), protargol (0.5-1 per 
cent.). If it has existed for some days, curet and pack with 
iodoform gauze. Careful antiseptic or aseptic cureting is the 
proper form of treatment in all forms of endometritis, whether 
complicated or uncomplicated. In serious cervical lesions, 
with much e version and thickening of the mucous membrane, 
cureting should be associated with Schroder's operation upon 
the cervix. Drainage is of incalculable advantage in endo- 
metritis when complicated with slight catarrhal salpingitis. 
It will also prove serviceable in mild forms of periuterine in- 
flammation. Cureting should be considered contraindicated 
in well-established pathologic changes in the adnexa and in 
chronic peri-uterine inflammation unless immediately pre- 
ceded, at the same operation, by an abdominal incision for 
the correction of the pelvic lesions. In addition to curetment, 
intra-uterine treatment consists in the employment of anti- 
septics and caustics. Free drainage should be considered as 
a prerequisite to all intra-uterine treatment. The inflamed 
uterine canal is similar to a sinus. Unless the pent-up dis- 
charges have free vent, the irritation is aggravated. When 
the canal is patulous, large injections of a feeble antiseptic 
solution through a return-current catheter can be employed, 
such as formalin (i : 2000), normal salt solution, or a two per 
cent, solution of bicarbonate of soda. The latter solutions, 
when used, are as salutary as the more distinctly defined 
germicidal agents. If the cervical canal is insufficiently large, 
it should be dilated with laminaria tents, after which irri- 
gation should be practised. In mild cases the canal may be 
swabbed, by means of a cotton-wrapped applicator, with tinc- 
ture of iodin ; in more severe cases, with carbolic acid. When 
the mucous membrane is thickened, and tends to bleed or to 
furnish a profuse discharge, more active agents may be em- 
ployed: silver nitrate, gr. xxx, to aq. destil., Sss-j; zinc chlorid, 
oj-iv, to f oj ; acid, chromic, gr. x-xxx, to f Sj ; fuming nitric 
23 



354 GYNECOLOGY. 

acid, acid nitrate of mercury, tincture of chlorid of iron, pencils 
of silver nitrate, zinc chlorid, zinc sulphate, copper sulphate, 
or formalin. When strong caustics are used, precautions 
must be practised to protect the healthy vagina from con- 
tact with the solution. A mass of absorbent cotton should 
be placed beneath the cervix prior to the application, and 
the superfluous caustic should be removed by sponging before 
the pledget is withdrawn. Pencils are objectionable in that 
they produce sloughing of the cervical mucous membrane 
and cause the development of atresia. 

Tampons.— IntTa-nterme treatment should be supplem.ented 
by placing beneath the cervix a tampon, preferably saturated 
with a preparation of glycerin, a 50 per cent, solution of boro- 
glycerid in glycerin, a 10 to 15 per cent, solution of ichthyol 
in glycerin, or a 25 per cent, ointment of ichthyol in lanolin. 
The following prescription is an excellent astringent and anti- 
septic : 

K. Pulv. alum., f^j 

Acid, carbolic, .^ v j 

Glycerin., Oj. 

Various ointments, either astringent or alterative, with 
lanolin as a base, may be used upon the tampon. A tampon 
improves the circulation by raising the uterus to a higher level 
and maintaining it there. The antiseptic tampon may be 
retained from twenty-four to seventy-two hours according to 
its character. When the tampon is not used, or after its re- 
moval, a vaginal douche of two or three quarts of hot water 
(110° to 120° F.) should be used twice daily, with the patient 
in the recumbent position. When using very hot injections 
cover the vulva and perineum with vaselin, to prevent burning. 
The employment of rock salt, an ounce to the quart, in a douche, 
promotes its efficiency. Scarification under continuous irri- 
gation will often prove of advantage, and is more effective 
than leeches. An iodoform gauze tampon should follow. Intra- 
uterine injections have been employed for endometritis, but 
should never be used unless the canal is sufficiently patulous 
to permit the escape of the superfluous fluid. The preferable 
plan is to employ a pipet or syringe by which one, two, or three 
drops may be introduced. Occasionally, even this small quan- 
tity will cause violent uterine colic. These attacks are not 
necessarily dangerous, but they are not calculated to encourage 
the continuation of treatment. 

The treatment par excellence in chronic endometritis is 
the use of the curet. In senile endometritis the important 
consideration is drainage; to insure this, it may sometimes 



INFLAMMATIONS. 355 

be necessary to employ a tube. The cavity should be frequently 
irrigated with an antiseptic solution. 

377. Chronic Metritis. — Chronic metritis is an inflammation 
in the muscle-wall of the uterus, leading, when long continued, 
to increased connective tissue formation. The term metritis 
is used in a comprehensive sense, and comprises conditions 
which have been described by dift'erent writers under such 
terms as chronic parenchymatous inflammation (Scanzoni) ; 
subinvolution (Simpson) ; diffuse proliferation of connective 
tissue (Klob) ; infarction (Kiwisch) ; hyperplasia of fibromuscular 
tissue, similar to fibroid tumors fVirchow) ; diffuse interstitial 
metritis fXoeggerath) ; irritable uterus (Gooch). The term 
may be criticized from a pathologic standpoint, as there is 
no chronic inflammation of the muscle-fiber of the uterus, 
but an increased amount of connective tissue, out of proportion 
to that of the muscle-fiber. Clinically it is satisfactory, as 
it enables us to comprise under one term a variety of conditions 
which may be developed from dift'erent causes but produce 
a similar group of symptoms. It has been objected to this 
term that, by inference, there has been a profuse acute inflam- 
mation, which is not the case, as chronic inflammation of the 
uterus does not follow the acute. It is more correctly described 
as an increased tissue formation, dependent on long-continued 
congestion. The term chronic is applied to analogous forms 
of inflammation in other organs and structures of the body, 
as cirrhosis of the liver, which describes a condition similar 
to that which is found in the uterus. Subinvolution is, in 
some English books, described separately, though it is due to 
the same cause. 

The dift'erential diagnosis between subinvolution and chronic 
metritis is impossible, and the treatment of the two conditions 
does not differ. The altered condition of the uterus will vary 
with the period at which the patient comes under observation. 
In the early stages the organ is enlarged, hyperemic, and soft. 
Later, it may decrease in size, though it is still large, and then 
becomes hard, indurated, and anemic. The enlargement of 
the organ is uniform, so the shape is not altered. Upon open- 
ing the abdomen of such a patient, the peritoneal surface will 
present a normal color, or patches of extravasated blood may 
be present. On section, in the early stages the tissues will 
be soft, hyperemic, easily incised; later, firm, cartilaginous, 
presenting a whitish color, the walls thickened, and the cavity 
of the uterus enlarged. Not infrequently the organ will be 
found as firm and dense as a mature fibroid growth. During 
the first period, De Sinety says, the dominant lesion is the 
presence of a large number of embryonic elements through- 



356 GYNECOLOGY. 

out the thickness of the muscular wall. These are more par- 
ticularly situated around the blood-vessels, or they may form 
islands more or less separated from one another. The second 
period is characterized by two changes: first, marked. dilatation 
of the lymphatic spaces; second, localized hyperplasia around 
the blood-vessels. We may find it difficult to determine whether 
the muscular tissue remains normal, or is present in decreased 
quantity. Fritsch examined uteri removed for cancer, and 
found associated evidences of chronic metritis, in which the 
following pathologic changes were noticed: The arrangement 
of the muscular fiber and connective tissue is less regular than 
in the normal, and the latter is greatly increased in quantity. 
Blood-vessels are more numerous and tortuous. The vessel 
lumen is contracted, its tunica media is thickened, and the 
contour of the vessel is masked by the degeneration of the con- 
nective tissue in its wall. The lymphatic spaces, instead of 
being narrow clefts, are gaping; the peritoneum is thickened. 
Both Corneuil and Snow-Beck described an increased num- 
ber of round and oval globules with amorphous tissue in the 
uterine walls. The increase in the size of the organ is due to 
the presence of this rather than to the increase of muscle-fiber. 
378. Etiology. — The causes of chronic metritis are divided 
into two classes : the predisposing and the exciting. The former 
may be divided into: (a) Those which operate by interference 
with the normal involution of the puerperal uterus; (b) those 
which are due to the production of repeated or protracted 
congestion. The first class comprises: first, retentions within 
the uterus of portions of placenta, membranes, or blood-clots; 
second, cervical lacerations; third, pelvic inflammations subse- 
quent to labor; fourth, too short convalescence following de- 
livery; fifth, nonlactation ; sixth, repeated miscarriages. Two 
factors are essential to the accomplishment of involution: 
first, fatty degeneration of the muscle-fiber; second, removal 
of the products of degeneration. Now, subinvolution or failure 
of the uterus to undergo complete involution is due not to want 
of degeneration of muscle-fiber, but to substitution of con- 
nective tissue for the products of this degeneration. Metritis, 
then, is generally found in women who have borne children, 
and it has been asserted that involution is retarded by the 
removal of the ovaries, although a patient of mine who 
completed her gestation after the removal of both ovaries 
did not manifest any failure in the process of involution. Any 
irritation in or about the uterus will cause a chronic metritis, 
and this explains the effect of retention of portions of the placenta 
or membranes, of lacerations of the cervix, and of the existence 
of peritonitis or cellulitis, as these conditions interfere with 



INFLAMMATIONS. 357 

the circulation, which is also affected by premature getting 
up following labor. The organ is heavy, and the increased 
weight leads to its being displaced to a lower level, producing 
passive congestion. Passive congestion is decreased by any 
cause which increases uterine contractions; the physiologic 
stimulus of nursing excites contraction refiexly through the 
mamm^ and favors involution. Abortions are especially in- 
strumental, for the reason that the patients do not take so much 
care of themselves as they would subsequent to a labor, and 
the stimulus of lactation is absent. After an abortion con- 
ception is likely to occur before the process of involution is 
complete, and this favors the recurrence of abortion. 

The second class of cases, which operate through production 
of repeated or protracted congestion, includes displacements 
of the uterus, the presence of tumors in or near it, and causes 
that produce increased flow of blood to the uterus, such as 
endometritis and the free use of caustics. To this class also 
belong malformation, incomplete development, congenital ante- 
flexion, conic cervix, stenosis of os, improper clothing, expo- 
sure to cold, and masturbation. Metritis is favored at each 
menstrual period, by exposure to cold, especially when the 
uterus is displaced or the cervix is contracted or lacerated, by 
excessive copulation or its practice during menstruation, and 
by gonorrheal infection from an incompletely cured husband. 

Chronic contusions from the use of a pessary may engender 
the inflammation. The intra-uterine stem-pessary is capable 
of doing the most injury. 

379. Symptoms. — In the large majority of cases the patient 
will date her trouble from a confinement. Not infrequently 
she will report repeated abortions, and that she subsequently 
regained her health very slowly. 

The symptoms are not characteristic, but are similar to 
those found in cancer, fibroma, displacements, and other local 
disorders. They are: weakness; pain or aching over the lower 
lumbar and sacral regions; a sensation of weight and bear- 
ing down, as if the pelvic organs were to be extruded; an ap- 
parent loss of power in the limbs; points of anesthesia over 
the anterior surface of one or both thighs; painful contractions 
of the uterus ; irritable bladder ; constipation ; loss of all pleas- 
surable sensation during the sexual relation; pricking pain 
in the eyes and weak sight; photophobia; occipital pain, but 
more frequently pain over the coronal suture ; and disturbances 
of menstruation, as dysmenorrhea, abnormal bleeding, menor- 
rhagia, or metrorrhagia. In weak patients are found amen- 
orrhea, leukorrhea, hydrorrhea, hydrorrhoea gravidarum, puer- 
peral hydrorrhea associated with retention of portions of placenta 



358 GYNECOLOGY. 

and clots. Not infrequently there is loss of appetite, nausea, 
dyspepsia, and enfeebled assimilation. The patient is pale, 
anemic, and exceedingly weak, with dark circles beneath her 
eyes. She suffers from palpitation and a sense of oppression, 
and is exceedingly despondent, and profoundly melancholic. 
Acute mania, epilepsy, hysteria, and neurasthenia are occasion- 
ally induced, and are alw^ays aggravated by the existence of 
chronic metritis. The diseased condition under discussion is 
responsible for the majority of cases of semi -invalidism. The 
patient is continuously conscious that she has a uterus; the 
distress is increased by exercise and lessened by rest. The 
constipation and digestive disturbances are aggravated and 
increased by dread of pain and by her sedentary habits. The 
patient can suffer from acute exacerbations, with diarrhea and 
rectal tenesmus, as a result of extension of the inflammation to 
the rectum. 

Menstrual disturbances are common, largely induced by 
the accompanying endometritis, called, from the bleeding, 
hemorrhagic endometritis. 

The hemorrhage is probably quite as often due to the dimin- 
ished contractile power of the organ, from the substitution 
of connective tissue for the muscle-fiber. The associated 
disease of the mucous membrane adds to the dysmenorrhea, 
which may precede, be simultaneous with, or follow the period. 
It is generally continuous with the period, in the form of in- 
creased backache, pressure, and pelvic discomfort. 

Leukorrhea is produced by alterations of the uterine mucous 
membrane. In the aged not infrequently a hydrorrhea de- 
velops, with a periodic discharge so offensive as to lead to the 
suspicion of the development of malignant disease. 

Sterility is a natural consequence of the prolonged existence 
of chronic inflammation, not only from alterations in the struc- 
ture of the wall and mucosa, but probably much more from 
the superadded changes in the pelvic peritoneum, affecting 
the tube and ovaries. The escape of the ovum may be pre- 
vented by extensive adhesions fixing the ovary, or through 
thickening of the ovarian tunica albuginea, which prevents 
its exit from the maturing Graafian follicle. The Fallopian 
tube may furnish the obstacle, through closure of its abdom- 
inal or uterine end, or by stricture along its course. 

In the earlier stages of the inflammation the susceptibility 
to pregnancy may be engendered by the conditions, while 
the existing changes unfit the internal uterine surface for the 
complete nutrition of the developing embryo, and abortion 
or premature discharge of the contents follows The sub- 
stitution of connective for the muscular tissue, through the 



INFLAMMATIONS. 359 

consequent uterine inertia, when gestation is completed, renders 
delivery tedious and increases the danger of postpartum bleed- 
ing. 

Chronic metritis is responsible for a large proportion of 
the sofa and bath-chair population — the nervous, debilitated, 
dyspeptic women who wander from physician to physician 
or crowd the watering-places during the summer. The con- 
dition is frequently unrecognized and untreated, and the patient 
is condemned to suffer- deeper and deeper wretchedness. 

380. Physical Signs and Diagnosis. — The uterus is large, 
without a change in shape. The walls are firm and rigid, in 
later stages almost as resistant as a fibroid tumor. 

The organ ma}^ have a normal position, may be situated 
at a lower level, or may be displaced. It may be freely movable 
or more or less fixed; readily outlined or fixed in a mass of 
pelvic exudate. The organ is sensitive to pressure. 

Differential Diagnosis. — Pregnancy in the early stages pre- 
sents a history of cessation of menstruation and of increased 
discharge. The uterus is enlarged, the cervix soft, while the 
body bulges like a jug, and is not resistant. Cancer usually 
involves the cervix, though the body may be the site of origin. 
In the latter the bimanual examination will show points of 
increased resistance. Bleeding results from severe manipu- 
lation, and an offensive, thin, and serous discharge w411 prob- 
ably be present. Pain is a frequent symptom, and occurs 
most severely toward evening. The use of the curet or digital 
exploration after dilatation with tents may be required to 
insure the diagnosis. The cureted tissue in cancer will be 
friable from infiltration, exhibiting under the microscope the 
characteristic cellular structure. 

Small fibroids are frequently difficult to recognize, especially 
when interstitial or submucous. The irregular enlargement, 
well-defined points of resistance, and frequently intermittent 
pain are diagnostic. Digital exploration of the uterine cavity 
determines the presence, size, and situation of the growth. 
Salpingitis is often associated with metritis, when it may be 
difficult to determine w^hich predominates. A small ovarian 
tumor may be the cause of hemorrhage. 

Rectal disease may produce symptoms simulating chronic 
metritis. The general health may be so aff'ected as to cause 
the local manifestations to be overlooked. Thus, the patient 
may complain of persistent cough, difficult, breathing, or pro 
gressive emaciation, or the stomach may be the source of trouble, 
causing loss of appetite, flatulence,, and gurghng, and present 
ing evidences of dilatation. She may have precordial anxiety 
palpitation, or cardiac and vascular murmurs. 

r 



360 GYNECOLOGY. 

It is a good rule to make a careful uterine examination 
in all cases of chronic disease. 

381. Course and Prognosis. — Metritis in all forms is obsti- 
nate and rebellious. The mucous membrane, muscular wall, 
and serous covering in turn are affected, followed by uterine 
sclerosis, cyst formation, and, finally, chronic metritis. In 
alterations of structure we can not hope to cure in the sense of 
restoration of altered tissues; we can hope only for arrest of 
the process, relief of congestion, and amelioration of unpleasant 
symptoms. 

382. Treatment. — The best treatment is preventive. It 
consists in thoroughly emptying the cavity of the uterus after 
labor; in early repair of lacerations; in the relief of inflam- 
matory conditions existing about the uterus; in stimulating 
involution of the organ by hot vaginal douches; in the ad- 
ministration of ergot and of remedies that will facilitate the 
contraction of its muscle-fibers ; in the exercise of such measures 
as will diminish congestion; in preventing the patient from 
rising too early from bed after pregnancy or abortion, and, 
when the condition subsequently exists, obliging her to remain 
in bed several hours daily, and to avoid sedentary occupations 
and long standing. While it is important that the patient 
should have sufficient rest, it is equally desirable that this 
should not be excessive. A certain amount of exercise in the 
open air is as desirable as rest. Tight clothing should be ex- 
cluded. If the abdominal muscles, however, are very much 
relaxed, a snugly fitting abdominal binder affords great com- 
fort and relief. This relaxation of the abdominal muscles is 
not infrequently associated with relaxation of the vaginal 
walls, when the use of a ring-pessary gives comfort. The 
circulation of the pelvis should be stimulated by vaginal douches 
of either hot or cold water. The latter are more stimulating, 
but few patients can employ them. Patients should take 
a hot douche containing rock salt, at a temperature of from 
103° F. to 120° F., for ten or fifteen minutes before retiring. 
These douches are more effective when the patient is in the 
recumbent position. She can lie across the bed with her pelvis 
upon a basin or rubber pad, which should drain into a pail 
below, while her feet rest upon chairs. A douche bag, con- 
taining at least three pints, should be placed three feet above 
the level of the patient. Prior to its use the vulva and peri- 
neum should be coated with vaselin, to protect from the heat. 
The tube should be introduced to the cervix, and from three 
to ten pints of fluid should be used with each douche. Occa- 
sionally, warm baths should be used simultaneously with the 
vaginal douche. A cold hip-bath in the morning will be of 



INFLAMMATIONS. 361 

great service. Medicated baths and waters are often of value. 
A course in hydrotherapy will frequently be serviceable. In 
catarrh or in scrofulous and chlorotic patients iron waters are 
beneficial. In nervous patients the character of the water 
is unimportant, but the patient should be encouraged to take 
large quantities. With d^'^speptics, alkaline waters are desir- 
able. In the lymphatic and scrofulous cases waters impreg- 
nated with chlorid of sodium are very efficient. These are 
also of value in some forms of chronic metritis where engorge- 
ment of the uterine body predominates. Patients not infre- 
quently derive great advantage from change of air or scene, 
new surroundings, new relations, or a visit to the seashore 
or country. Constipation should be combated, preferably 
with foods, such as vegetables, Graham bread, and prunes; 
often effectively with other agents, as a teaspoonful of white 
mustard in Avater at meals ; enemata to which glycerin is added ; 
the administration of mineral Avaters — the Friedrichshall water, 
Carlsbad salts, or Hunyadi Janos. The Carlsbad salts are of 
particular value in bilious patients. A teaspoonful should be 
dissolved in a glass of water and drunk in repeated sips during 
the morning. Friedrichshall and Hunyadi act best Avhen 
mixed with equal quantities of hot Avater. A good mixture is 
a tablespoonful of the folloAAing preparation : 

R . Magnesia sulph., ^ vj 

Quinia sulph gr. xxiv 

Acid, sulphuric, dilut., 

Tr. capsicum, ^^ i^j 

Aquam ad f 5 vj. M. 

SiG. — Tablespoonful three times daily. 

Contraction of the uterine muscles may be increased by 
the administration of ergot, Avhich should be given in doses 
of gtt. XX to foj, t. d. When the condition is complicated 
Avith menorrhagia, extract of hydrastis canadensis may be 
combined. An effective prescription Avould be a mixture 
of ergot and hamamelis. (Section 156.) Potash salts are 
especially beneficial in chronic inflammation of the uterus. 
Chlorate of potash is highly recommended by Tait. lodid 
of potash, hoAA^CA^er, is equally effective, and, when the patient 
is nerA'ous and restless, may be combined AA^th a bromid, giA'ing 
of the iodid gr. a^ AA^th bromid gr. x, largely diluted AA^th AA^ater, 
three times daily. Potash salts may be administered in the 
bitter tonics, as in compound tincture of cinchona or compound 
tincture of gentian. In the anemic and debilitated, iron, 
strychnin, quinin, arsenic, cod-liver oil, and malt extracts 
will proA^e beneficial. The general health should be carefully 
Avatched and any deranged condition of the A'arious organs 



362 GYNECOLOGY. 

should be corrected. During the menstrual period patients 
should be confined to the sofa. When the pelvic distress is 
marked, or when the metritis is complicated by inflammation 
in the surrounding structures, benefit will be derived from 
the use of count erirritants, in the form of small blisters over 
the inguinal region, or the use of iodin or of croton oil. A 
good mixture is croton oil, one part; tincture of iodin, two parts; 
sulphuric ether, five parts, which can be painted over the hypo- 
gastric and iliac regions until a crop of pustules arises. The 
application should then be discontinued until they have healed. 
Exercise care not to allow the application to be made in the 
groin. Blistering fluid may be applied to the cervix and to 
the vault of the vagina, or tincture of iodin, or a combination 
of tincture of iodin and glycerin, may be thus used. Scanzoni 
advocated this application : 

R . Potas. iodid., . . . = gr. iv 

Glycerin., tt\^xxx. 

When cervical catarrh complicates the condition, punctur- 
ing or scarifying the cervix, under an antiseptic stream, will 
be beneficial. Considerable depletion can thus be effected 
and the patients relieved. After the bleeding has stopped, a 
tampon of cotton and gauze, associated with one of the prep- 
arations of glycerin, will prolong the depletion. A tampon 
raises the uterus to a higher level and improves its circulation, 
while, medicated with glycerin, it has a depletive or cholagog 
effect upon the vessels of the cervix, causing a profuse watery 
discharge. The patient may be instructed how to introduce 
these tampons, and may use them daily. A tampon saturated 
with a 50 per cent, solution of boroglycerid in glycerin, a 10 
to 20 per cent, solution of ichthyol in glycerin, or carbolic acid 
(i : 16) may be kept in place for one to two days. A tampon 
anointed with one part of ichthyol to four of lanolin is valuable 
when more or less irritation of the vagina is associated with 
the uterine lesion. In laceration of the cervix, where it has 
subsequently become hypertrophied, Emmet's operation is of 
service in relieving the congestion and promoting involution 
of the organ. If the cervical mucous membrane is much everted, 
with papillary projections and eroded surfaces, amputation 
of the cervix by the single-flap method advocated by Schroder 
(Section 268) will be more effective. Any disturbances of 
menstruation, such as dysmenorrhea and menorrhagia, should 
receive treatment suitable for endometritis. (Section 365.) 
For this condition, as well as for the chronic metritis, dilatation 
and curetage of the uterus are of value. The dilatation is pref- 
erably done with Pratt's dilators, as these instruments gradually 
stretch the uterine canal without danger of tearing, unless 



INFLAMMATIONS. 



363 



the dilatation is excessive, which may occur in the use of the 
parallel bar dilators. 

After preparation of the patient (Section ii8) she is placed 
upon her back, the uterus is exposed by the Edebohls speculum, 
the cervix is seized and fixed with a double tenaculum, and 
the bougies are introduced, thus gradually dilating the cervical 
canal. The dilatation is followed by the use of the curet. 
This instrument may be blunt or sharp ; the latter is preferable, 
if carefully used. The handle of the instrument should be 
perforated, so that the surfaces can be irrigated as the cureting 
is done. The instrument is held lightly, between the thumb 
and finger, and is passed into the uterus and drawn down on 
all sides of the organ in long sweeps, paying particular attention 




Fig. 290. — Uterus Dilated with Graduated Bougies. 



to the angles of the body and to the orifices of the Fallopian 
tubes. The use of the curet in this manner does not remove 
the entire mucous membrane; even though it did, the mucous 
membrane would be regenerated from the portion of the glan- 
dular structure which penetrates the muscular wall. The 
curetage may be followed by swabbing out the cavity of the 
uterus with tincture of iodin, with a combination of tincture 
of iodin and carbolic acid, perchlorid of iron, or preferably 
a saturated solution of iodoform in ether. When any of these 
agents, except the latter, are used, the irrigator should be in- 
troduced, again washing out the cavity of the organ, thus 
removing any clots and superfluous medicine. If the discharge 
of blood is slight, the uterine cavity need not be packed. If 



364 



GYNECOLOGY. 



there is considerable discharge, it should preferably be packed 
with iodoform gauze. Gauze packing is serviceable in that it 
first acts as a tampon, decreasing the danger of bleeding or 
of the formation of a clot of blood, which might become in- 
fected and give rise to extension of inflammation to surround- 
ing structures. Second, by its pressure upon the surface it 
favors the throwing-out of exudation and shuts off the en- 
trance of septic material into the uterine sinuses; third, by 
its capillary action it affords a limited amount of drainage; 
fourth, by its presence as a foreign body it stimulates uterine 
contraction and facilitates the process of involution. The 
vagina is carefully cleansed and a gauze pad is placed within 









- ' 








-^ 


">'^ ^^— •"■" 


% 


\ 






a 





Fig. 291. — Uterine Cavity Packed with Gauze after Dilatation, 



it, thus raising up the uterus. This gauze dressing may be per- 
mitted to remain two or three days. After its removal the 
vagina should be irrigated once or twice daily with a bichlorid 
or formalin solution. When the uterine cavity has been the 
seat of extensive inflammation, with a predisposition to hem- 
orrhage, the removal of the gauze may be subsequently fol- 
lowed by uterine irrigation through a double-current catheter. 
In hydrorrhea or pyometra in the aged it is very important 
to make sure that drainage is complete. The accumulation 
of fluid within the uterine cavity results in the formation of 
a sac of this organ, the contents of which may become infected 



INFLAMMATIONS. 365 

and produce an occasional profuse discharge, which may cause 
the greatest alarm on the part of the patient. Drainage in 
such cases should be insured; when necessary, by the intro- 
duction of a drainage-tube, through w^hich the cavity is well 
irrigated and cleansed. Remedies should be applied to the 
uterine cavity which will establish a healthy inflammation 
and arrest the abnormal accumulation. When the uterus 
is displaced, associated with hydrometra or pyometra which 
a pessary fails to correct, the advisability of extirpation of 
the uterus should be considered, particularly if the woman 
has passed the climacteric. Uterine adhesions or peri-uterine 
inflammation need not necessarily contraindicate curetage, 
as not infrequently the increased drainage thus secured will 
result in the relief of the peri-uterine disease. In patients 
who have suffered for a great length of time, who have become 
exceedingly nervous, hysteric, with general health destroyed, 
suffering from delusions or illusions, exceedingly instable tem- 
per, a source of worry and distress to the family and to them- 
selves, no better plan of treatment can be instituted than that 
advocated by Weir Mitchell as proper for neurasthenic patients. 
This treatment consists in placing the patient in bed; at first 
upon a distinct milk diet, with careful regulation of the bowels, 
correction of disordered condition of the alimentary canal; 
and, later, forced feeding, with as large a quantity of food 
as the patient can properly digest. She is under the control 
of a discreet, careful nurse, who allows her to take no exercise 
nor even to move without assistance. In place of exercise 
she is given, once daily, thorough massage, thus carrying for- 
ward the blood-current, stimulating the absorption of waste 
material, and causing the introduction into the uttermost 
parts of the body of blood containing oxygen. The anemia 
which characterizes such patients is thus rapidly overcome, 
the number of red blood-corpuscles greatly increases, while 
the elimination of waste material is promoted. Once a day 
she is given an application of the faradic current — general 
faradization. She is isolated from the members of her family, 
and during this period of isolation is brought under careful 
mental discipline, which aims to stimulate her ambition, to over- 
come the condition by which she has become subjected, so 
that by the end of six weeks or two months the patient under- 
goes a complete physical and mental change. 

383. Inflammation of the Fallopian Tube. — Inflammation 
of the tubes is a frequent result of infection, and the gravity 
of the physical changes is directly in proportion to the viru- 
lence of the poison. Gonorrhea and sepsis are the most fre- 
quent forms of infection which invade these organs. The 



366 



GYNECOLOGY. 



invasion may occur through the uterus by the continuous 
mucous membrane, or through the blood-vessels or lymphatics; 
the former being the more frequent. The inflammation may 
involve the mucous membrane, the muscular wall, and even 
the peritoneum. It may be catarrhal or suppurative. Gon- 
orrheal infection most frequently reaches the tube by the 
continuous mucous membrane of the uterine body, and is more 
prone to involve the tubal mucosa, resulting in either catarrhal 
or suppurative salpingitis. It may, however, pass rapidly 
through the surface epithelium into the deeper structures of 
the tube, and causes profound destruction. Other avenues 




Fig. 292. — Acute Salpingitis. 
a, Swollen and edematous fold, b, Inflammatory exudate, c, Dilated blood- 
vessel, d, Desquamation of epithelium, e, Infiltration of leukocytes. /. 
Disintegration of longitudinal fold. 



for the entrance of infection are an inflamed or diseased ap- 
pendix, especially upon the right side, through adhesions to a 
knuckle of intestine, especially where the tube contains a col- 
lection of blood, and, finally, through the peritoneum, which, 
however, is generally tubercular. The entrance of infection 
is followed sooner or later by evidences of inflammation. The 
epithelium becomes swollen, edematous, and granular, with 
the infiltration of inflammatory materials into the deeper layers. 
Serous effusion takes place into the tubal canal. (Fig. 292.) 
Loss of the cilia from the epithelium also occurs, especially 



INFLAMMATIONS. 



367 



upon the free surface, while they may be retained upon that 
portion between the folds. The epithelium will be found well 
preserved upon the surface of the tubal mucous membrane 
even when suppurative processes exist. (Fig. 293.) The 
irritating discharge from the tube early leads to irritation of 
the peritoneum and agglutination at the abdominal end of 
the tube, while the swollen structures obstruct the uterine 
orifice. The exudate which collects in the tube may be serous 
or purulent, according to the virulency of the infection and 
the resistive force of the patient. In either case the exudation 
is likely to increase, forming a clear serous collection in the 




Fig. 293.— Chronic Salpingitis showing Agglutination of Folds. 

a, Union of folds forming gland-like areas, b, Thickened and retracted fold. 

c. Desquamation of epithelium, d-, Hyperplasia of tubal wall. 



one case, which is known as hydrosalpinx, or sactosalpinx, 
while the more virulent process (Fig. 294), which results in a 
more or less extensive pus collection, is called a pyosalpinx. 
(Fig. 295.) Occasionally the excessive hyperemia or a partial 
twisting of the base may cause rupture of the blood-vessels 
with an intra tubular accumulation of blood. This condition 
is denominated hematosalpinx. The latter condition, how- 
ever, is more frequently associated with the retrogressive pro- 
cesses of ectopic gestation. As a result of the inflammatory 
process the tube ma}^ assume the form of a simple sac, which 
gradually becomes distended until it attains a large size, and 



368 GYNECOLOGY. 

presents as a thin-walled cystic tumor. If the peritoneal wall 
has not been involved, the tumor may remain freely movable, 
whether it contain serum or pus. Such a sac may, occasionally, 
become twisted upon itself until the venous circulation is par- 
tially or completely obstructed, and then rapid increase in 
size results from the hemorrhage, which takes place not only 
into the sac, but also, occasionally, into the peritoneal cavity. 
A young girl recently came under my observation in whom 
there had been an apparent acute exacerbation. Examination 
revealed a large mass upon either side, that on the left side 
being situated above the uterus, and that on the right pos- 
terior to and below the fundus. An operation was advised 





Fig. 294. — Extensive Pus Collections with General Adhesions. 

and subsequently performed. This revealed so much blood 
as soon as the abdomen was opened as to arouse the suspicion 
of an ectopic gestation. The hemorrhage in this patient came 
from the tumor of the left tube, the neck of which was twisted 
near the uterus. The tubal sac was dark (Fig. 298), and covered 
with clotted blood, which also filled that side of the pelvis. 
The right sac was clear and free from blood. Both sacs were 
found to contain pus, the left being mixed with blood. Both 
tubes were free from adhesions. Sometimes the distention of 
the tubal sac overcomes the swelling of the mucous membrane 
of the uterine end and, therefore, its opening remains patulous 
and permits its contents to escape, after which the sac attains 



INFLAMMATIONS. 



369 



a favorable position. Such a condition may lead to occasional 
discharges of a considerable quantity of fluid through the uterus, 
giving rise to the phenomenon known as hydrops tub^ pro- 
fiuens, or intermittent hydrosalpinx. Inflammation of the 
tube involving its muscular wall causes a shortening of its 
longitudinal muscular fibers, which, owing to the contractile 
action of the subserosa, permits the fimbria to be draw^n into 
the tube and the peritoneum to be pushed over it like the pre- 
puce over the glans penis 
in phimosis. (Fig. 299.) 
The peritoneal edges com- 
ing in contact are agglu- 
tinated, and the tube is 
sealed up. If the fimbrice 
are not completely w4th- 
drawm, the protruding fim- 
briae may serve as an 
avenue for leakage in sub- 
sequent distention of the 
sac and thus cause recur- 
ring attacks of localized 
peritonitis. (Fig. 300.) 

The tubal inflamma- 
tion, instead of forming 
the cystic tumor already 
described, may result in 
extensive small-cell infil- 
tration and thickening of 
the longitudinal folds, 
which necessarily decreases 
the caliber of the tube. 
Furthermore, in places the 
edges of the folds lose their 
epithelium, become more 
or less adherent, and upon 
microscopic section pre- 
sent the appearance of dis- 
tended glands. Such a 
condition has been caUed salpingitis cysto-adenosa, but this term, 
like salpingitis follicularis, pachysalpingitis, and other designa- 
tions, is an unnecessary distinction. The inflammatorv infiltra- 
tion frequently involves the folds and wall of the tube, producing 
such hyperplasia of these structures as to almost obliterate the 
tubal canal, and to form a large sclerosed mass. The contraction 
of the circular fibers may cause the formation of a series of 
small sacs, each one of which is independent of the other, and 

24 




Fig-. 



295- 



■P\-osalpinx. 



370 



GYNECOLOGY 



for which the only reHef is afforded by the extirpation of the tube. 

In the more virulent forms of infection the peritoneal surface 

of the tube be- 
comes involved 
by an extension 
through its ab- 
dominal end or 
through its walls, 
and extensive ad- 
hesions unite the 
organ to coils of 
the intestine, the 
uterus, the ovary, 
or the pelvic peri- 
toneum. The en- 
larged and swol- 
len tube drops 
down into the 
retrouterine cul- 
desac, and gener- 
allv becomes ad- 




Fig. 296. — Section from Wall of Pus-tube. 

a, a. Folds matted together forming gland-like 
spaces, b, b. Folds undergoing dissolution, c. 
Shows complete desquamation of epithelium 
covering folds. d, d. Blood-vessels distended 
with blood-cells, e. Leukocytic infiltration. 




Fig. 297. — Single Fold 
from Wall of Pus- 
tube, enlarged. Line 
through upper por- 
tion shows area of 
extensive hypere- 
mia. 



herent to the sigmoid flexure or side of the rectum. As 
the sac becomes more and more distended, the union thus 
formed may permit the establishment of a communication with 



INFLAMMATIONS. 



371 



the lumen of the bowel, through which the tubal abscess drains. 
The tube of one side, dropping into the pelvis, may become 
adherent to the extremity of the other and form a common 
pus cavity, which may attain a large size. (Fig. 301.) By 
a rupture of the tube, infection of Douglas' pouch may occur, 
thus filling the entire pelvis with a walled-of¥ abscess. The 
intimate association of 
the abdominal orifice 
of the tube with the 
ovary causes frequent 
adhesions between 
these organs, result- 
ing in intimate fusion 
of the involved struc- 
tures, and rendering it 
sometimes difficult to 
differentiate between 
the two organs. Oc- 
casionally they appear 
as a tubo-ovarian tu- 
mor or a fused inflam- 
matory mass, which 
may contain serous 
fluid or pus. 

384. Symptoms. — 
Tubal inflammation 
has no characteristic 
symptoms. If a pa- 
tient has had an acute 
pelvic inflammation, 
characterized by ex- 
treme tenderness in 
either pelvic region, 
and aggravated by 
motion, it is justifia- 
ble to conclude that 
the possible pelvic 
peritonitis has had its 
origin in a tubal in- 
flammation. "When each menstrual period is followed by 
pain and tenderness in the inguinal regions, tubal inflammation 
is very probable. A normal tube is not usually palpable. In 
diseased conditions, however, especially when the tube has 
become thickened by salpingitis or parenchymatous inflam- 
mation, it may be recognized as a more or less thickened cord 
which slips under the finger and is quite sensitive. When 





X 



Fig. 298. — -Distended Pus Tubes Removed from 

Young Girl. 
-4, Tube whose pedicle was twisted. Sac filled 

with blood and pus. B. Right tube filled 

with pus. 



372 



GYNECOLOGY. 




Fig. 299.- 



-Convoluted Fallopian Tube from. 
Perisalpingitis. 



hyperplasia of its connective tissue occurs, the tube is felt as a 
contracted, distorted, nodular mass, closely associated with 

the uterus and frequently 
firmly fixed in the pelvis. 
When the abdominal end 
is closed, it may present 
an enlargement increasing 
from the uterus outward, 
something like a bell-re- 
tort, or gourd, in shape, or 
resembling a sweet potato 
or sausage or sausage -like 
links. 

385. Diagnosis. — When 
the uterus is bound down 
with evidence of exten- 
.sive peritoneal inflamma- 
tion upon the sides, in 
the majority of cases the tubes will be found to have been 
the source of infection. In a normal condition, unless the 
patient is very thin, the tubes are not palpable. Inflammatory 
change, however, which renders the tubes resistant and causes 
them to be stiffened, 
leads to their recog- 
nition, so the deter- 
mination of a cord- 
like structure run- 
ning out from the 
side of the uterus is 
evidence of tubal in- 
flammation. Where 
the tubes become 
occluded at their 
abdominal ends, 
and filled with se- 
cretion, they be- 
come more and 
more retort-shaped, 
being larger at the 
external portion 
and narrowing to- 
ward the uterus. A 

tumor presenting such a shape as this, and quite movable, 
is most frequently a hydrosalpinx. (Fig. 302.) It is true that 
pus tubes may at times be free from adhesions, but in the 
majority of cases the infection which is so virulent as to lead 




Fig."3oo. — Incomplete Inflammatory Closure of the 
Fallopian Tube. Portions of Fimbriae Unre- 
tracted. 



INFLAMMATIONS. 



373 



to the formation of pus causes a perisalpingitis, Vhich leads 
to agglutination of the surrounding structures, and not infre- 
quenth'^ to absolute fixation of the pelvic structures. AA^here 
the tube is free from adhesions, it is likely to drop into Douglas' 
pouch. Here the change in the circulation not infrequently 
leads to it becoming adherent to the posterior surface of the 
uterus, the sides of the rectum, or the ovary and tube of the 
opposite side, forming a large mass filling up the pelvis. (Fig. 




Double Tubo-ovarian Collection. 



301.) These conditions are readily recognized by bimanual 
palpation. In practising this procedure, however, it is very 
important that it should be done with great precaution, re- 
membering that not infrequently these sacs may be so thinned 
that undue pressure may lead to their rupture with the escape 
of their contents into the peritoneal cavity, causing a general 
infection, to be followed subsequently by peritonitis. The 
association of the ovary in a mass of this kind, forming a tubo- 




374 GYNECOLOGY. 

ovarian abscess, is not always readily recognized. A tubo- 
ovarian cyst is more readily determined by the increase in 
size, by the greater spherical character of the external end of 
the sac, associated with a bell, or retort-like shape, as we ap- 
proach the uterus. 

386. Prognosis. — Tubal inflammation should always be con- 
sidered a source of danger. Even its mildest forms should 
necessitate resort to treatment, in order, if possible, to arrest 
the progress and limit the extension of the inflammation. When 
associated with pelvic peritonitis, the extensive infection, 
especially the streptococcic form, is one of the most dangerous 
lesions with which we have to deal. When associated with 
disease of the ovaries and extensive suppuration of the tube, 

the cure of the patient, in 
the sense of restoration 
of her functions, is abso- 
lutely impossible. While 
the patient may recover 
her health and comfort, 
she is subsequently crip- 
pled for life, because her 
powers of procreation are 
destroyed. 
Fig. 302. — Hydrosalpinx. Treatment.— {See Sec- 

tion 390.) 

387. Inflammation of the Ovary. — Inflammation of the 
ovary occurs in two forms: oophoritis, inflammation of the 
structure of the organ ; peri-oophoritis, where the inflammation 
is confined to its surface. A hyperemia or congestion of the 
ovary may arise as a result of infection. This may be so ag- 
gravated as to lead to rupture of vessels. The occurrence of 
hemorrhage into the structure of the ovary produces small 
collections of blood-clots in the organ, which is known as ovarian 
apoplexy, or a large collection of blood, when it is called an 
ovarian hematoma. The latter may destroy the ovary and 
even rupture its coat, and result in a serious internal hemorrhage. 
Oophoritis is an interstitial inflammation of the ovary, which 
may be either acute or chronic, septic or gonorrheal. It is 
characterized by all the signs of inflammation, hyperemia, 
swelling, increase in size of the vessels, extravasation of blood, 
and later pus formation. The latter may involve only a small 
portion of the ovary or the entire organ may become the seat 
of an abscess. The origin of the infection not infrequently 
arises in a corpus luteum, so we have what are known as corpus 
luteum abscesses. In these cases the walls of the abscess may 
be recognized by the wavy elevations of the inner wall on micro- 



INFLAMMATIONS. 



375 



scopic section. The acute form of the disease is most frequently 
the result of infection ; the latter gains admission through lesions 
of the vagina, of the uterus subsequent to labor or abortion, sur- 
gical operations, or an accidental injury. Infection may reach 
the ovary through the continuous mucous membrane of the 
tube or by way of the lymphatics or blood-vessels. In fatal 
cases the ovary will often be found very much enlarged, soft 
and sloughing, and containing small extravasations of blood 




Fig. 303.— Double Pyosalpinx Showing Adhesions to the Rectum, to the Uterus, 
and, on the Right, to the Appendix. 

or pus, or small collections of pus will be found in the con- 
nective tissue and structure of the ovary, or a single large abscess 
may exist, equal in size to a hen's egg or even larger. The 
larger abscesses may be produced by suppuration of an ovarian 
cyst. Suppurating ovaries generally become adherent to the 
neighboring structure, and, if the walls are thick, the pus may 
remain quiescent, thus being the cause of a chronic state of ill 
health. However, the pus may escape by rupturing into the 
bowel, bladder, or vagina. The cavity thus emptied may 



376 GYNECOLOGY. 

shrink and ultimately disappear, while a state of chronic ill 
health will still continue. An inflamed or cystic ovary, ad- 
herent to the inflamed tube, frequently loses the intervening 
wall and forms a concavity, which is known as a tubo-ovarian 
cyst or tubo-ovarian abscess. Coalescence of both ovaries 
and tubes in such a sac may result in the formation of a tumor 
which fllls up the pelvis. The formation of an abscess in the 
ovary is not always associated with peri-oophoritis. Some years 
ago I saw a patient in consultation, and subsequently operated 
upon her, in whom, some three weeks following her delivery, 
her temperature arose to 104° F. Careful examination failed 
to reveal any increase in the size of the uterus or anything to 
indicate that the uterus was the seat of disease. Some en- 
largement of the ovary upon the left side, which, however, was 
free from adhesions, led me to open the abdomen. After enter- 
ing the abdominal cavity, the left ovary was found the size of 
a small orange; it was free from any adhesions, but had a small 
flake of lymph on one side, which corresponded to a similar 
flake in the orifice of the tube. The tube itself was not enlarged 
nor did it show any signs of an inflammatory condition. The 
ovary was afterward removed and, when opened, contained 
within a thin shell some thick, greenish pus. The subsequent 
convalescence of the patient was uninterrupted. In chronic 
oophoritis there is a great increase in the connective tissue, 
which results in contraction and thus causes destruction of 
the follicles and compression and arrest of development of the 
stroma, while the epithelium of the free surface is the longest 
preserved. This may present extensive fissures, the result 
of the contraction. In chronic inflammation the tunica albu- 
ginea becomes greatly thickened, so it does not readily rup- 
ture with the development of the Graafian follicle. The con- 
sequence is, that the follicle increases in size, and such an ovary 
may present a large number of cysts, producing the condition 
known as cystic degeneration of the ovary. Another form 
of chronic inflammation of the ovary has been denominated 
oophoritis serosa. In this form the inflammation is chronic 
in development and duration, and in the majority of cases it is 
curable, if properly treated. It may be a sequel of fevers, 
sometimes it is associated with mumps, and it may follow 
a passive gonorrheal infection. The ovaries become swollen, 
exceedingly tender, and frequently prolapsed. In advanced 
cases they are greatly swollen, quite smooth, shiny, and almost 
translucent. Folds and cicatrices are completely obliterated. 
Cirrhosis is a term which has been applied to various changes 
in the ovary. I have frequently seen ovaries which were pro- 
nounced cirrhotic, but which I could not regard otherwise 



INFLAMMATIONS. 



377 



than as physiologic. The term is only applicable to those 
cases in which the ovary has undergone contraction to such a 
degree as to result in the destruction of its glandular tissue 
and decided decrease in size of the organs. 

Peri-oopkoritis is a condition characterized by the deposition 
of infiammatory material upon the surface of the ovary. The 
surface epithelium is destroyed and it is likely to be followed 
by a true oophoritis. . This condition, like simple oophoritis, 
is frequently a part of a widely extended infiammatory process, 
which may involve uterus, oviducts, ovaries, pelvic peritoneum, 
and cellular tissue (Fig. 304). It is generally consequent upon 
an extension of infection from the tubal orifice to the pelvic 
peritoneum, although it may follow an abscess of the ovary. 




Fig. 304. — ^Peri-oophoritis. Tube and Ovary Encysted. 



The end of the tube is usually associated with the ovary in 
this form of inflammation, and it may be the forerunner of a 
tubo-ovarian abscess. The inflammation varies from a few 
bands of adhesions which bind down the ovary and tubal orifice, 
possibly occluding the latter, to a mass of exudation which 
completely obscures both and forms so intimate a fusion as to 
render difficult the line of demarcation between these organs. 
The chief function of the ovary, apart from any supposed 
internal secretion, is to provide a site for the perfect develop- 
ment and maintenance of health}^ ova, and to permit them, 
under circumstances as yet undetermined, to pass into the 
mouth of the oviduct. Peri-oophoritis necessarily interferes 



378 GYNECOLOGY. 

with this process, by the presence of adhesions about the ovary, 
or the consequent induration of its tunic. An ovum escap- 
ing from a matured Graafian folHcle will be barred from en- 
trance into the oviduct, by adhesions which fix the fimbriated 
orifice or so envelop the ovary as to prevent it reaching the 
oviduct. Such adhesions are a cause of severe suffering, espe- 
cially when they limit the free mobility of the ovary and fix it 
subject to pressure, as behind the uterus or over the rectum, or 
where intestinal adhesions subject it constantly to dragging and 
tension by intestinal peristalsis. An ovary fixed in the retro- 
uterine pouch, with an overlying retro verted uterus, is a con- 
stant source of distress. Its position, independent of the ad- 
hesions, causes congestion from the obstructed circulation, while 
the pressure of. feces and the impinging male organ during coi- 
tion promote the discomfort. 

388. Symptoms. — Oophoritis exhibits no characteristic symp- 
toms. Even in cases of acute septic poisoning no symptoms 
will be present v/hich can be said to be absolute indications 
of an ovarian lesion. In the less severe form of infiammation 
we may recognize symptoms which we could justly attribute 
to ovarian disease, but they are so intimately associated with 
those caused by disease of the oviducts that it becomes difficult 
to differentiate them. Pain is the only constant symptom 
in all varieties of pelvic infiammation, and the site to which 
it is referred bears no constant relation to the affected organ. 
The entire pelvic region may be the seat of pain, but we are, 
however, unable definitely to distinguish the exact origin of 
pain and say whether it is due to affections of the tube, ovary, 
peritoneum, broad ligament, body of the uterus or cervix. 
We can readily appreciate this when we remember that the 
nervous distribution of the various organs is derived from a 
common symphathetic center. As in any infiammatory con- 
dition, pain is aggravated by pressure, so in infiammatory 
processes of the pelvic structures pain is magnified by pressure 
and motion. The pain is distinguished from that of true dys- 
menorrhea, by the fact that it is an exaggeration of the distress 
felt between the periods, while true dysmenorrhea is purely a 
menstrual pain. Not infrequently patients will assure us that 
the only time they are free from discomfort is during the men- 
strual flow. Pain may persist subsequent to coition as a result 
of congestive tension. When produced by intra-abdominal 
pressure and increased by standing, pain is greatly relieved by 
assuming the recumbent position. Ovarian pain is directly 
aggravated by pressure over the organs through the vagina 
or rectum, as during coitus, an examination, or the passage 
of large fecal masses. The various symptoms of pelvic disease. 



INFLAMMATIONS. 379 

such as amenorrhea, menorrhagia, or leukorrhea, are not char- 
acteristic of oophoritis. Peri-oophoritis causes pain which is 
more or less distinctly localized at the pelvic brim, and extends 
down the thigh of the affected side. Not infrequently pain 
is experienced in the corresponding breast. The inflammation 
may extend from the surface of the ovary into its substance 
and cause changes in its stroma, dropsy of its follicles or hem- 
orrhage, producing a condition in the one case known as cystic 
degeneration of the ovary, and in the other as ovarian hema- 
toma or ovarian apoplexy. The wide distribution of neurotic 
symptoms must not be overlooked. The local pelvic lesion 
may be a minor one. To oophoritis, or uterine displacement, 
are often attributed symptoms which are the result of fissures 
of the cervix, mobility of the kidney, enteroptosis, gastroptosis, 
or even central lesions of the nervous system, which will per- 
sist after the supposed local lesion has been cured or removed. 
Such experiences are a source of great disappointment to the 
medical practitioner. At times relief is obtained, at others 
pain and distress continue or are even aggravated. 

389. Diagnosis. — Inflammatory processes of the OA^ary do not 
present a constant characteristic clinical picture. The infection 
rarely confines itself to the ovary, consequently the sympto- 
matic phenomena are modified by the circumjacent inflamma- 
tory changes. The recognition of a tender body, somewhat 
enlarged, yet retaining the shape of the ovary, by vaginal or rec- 
tal palpation, adds certainty to the diagnosis. The presence of 
adhesions or exudate will render its determination difficult 
and make it doubtful how much the swelling is due to the 
ovary, the tube, or the exudate. In acute conditions or in 
hyperesthetic patients an anesthetic will prove of value. 
AVhere the obscurity of the condition can not be overcome a 
preliminary vaginal or abdominal incision may be necessary in 
order to determine the proper operative procedure. 

390. Treatment of Inflammation of the Appendages. — ^In 
the great majority of chronic inflammations of the uterine 
appendages the treatment of diseased conditions of the tubes 
is similar to that of diseases of the ovaries, or, in other words, 
the two conditions are so related that I felt it better to consider 
their treatment under the one section. The first aim in the 
treatment should be the preservation of the function of the 
affected organs. The second, the restoration of health to the 
patient. Treatment may be either medical or surgical. The 
medical or nonoperative treatment consists in rest in bed and 
in keeping the patient absolutely quiet. Free purgation should 
be established by the use of salines in order to make the in- 
testines drain the peritoneal cavity and relieve the congestion. 



380 GYNECOLOGY. 

The diet should be restricted and cold should be applied to 
the external surface. In the acute stage the application of 
cold in the form of the ice-bag is of value, and this should be 
kept more or less continuously applied. The ice-bag decreases 
the congestion, limits the exudation, lessens the danger of 
suppuration, and promotes absorption. After the more acute 
symptoms have subsided the treatment may still further be 
promoted by the application of pressure, using three to five 
pounds of shot in a bag, which is applied over the inflamed, 
indurated tissues; the pressure is increased and its position 
changed, as the condition may demand. Unless suppuration 
has occurred, resolution will probably be accomplished. The 
absorption may be still further promoted by the use of counter- 
irritants, such as small blisters, painting with iodin, the use 
of croton oil or inunctions of dilute ointment of the iodid of 
mercury or a dram of the official ointment to an ounce of lanolin. 
Occasionally ice will be very uncomfortable to the patient, while 
heat will be more grateful. A flaxseed poultice may be ap- 
plied, or, what is probably much more agreeable to the patient 
and more easily applied, would be to take a piece of spongio- 
pilin, wring it out of hot water, and place it over the abdomen, 
and over this a dry cloth. This should be changed as frequently 
as may be necessary. The changing may be made less frequent, 
however, by the application over it of a hot -water bottle. Ich- 
thyol in lanolin, one or two drams to the ounce, may be rubbed 
into the lower part of the abdomen, and this supplemented 
by the pressure already suggested. Hot vaginal douches 
should be employed, and benefit will frequently be obtained, 
by the use of hot rectal enemas, using a pint to a quart of hot 
water and directing the patient to retain it as long as possible. 
This is more effective than hot vaginal douches, for the reason 
that the heat comes more nearly in contact with the inflamed 
surfaces and can be retained for a greater length of time. In- 
ternal medication during this time, aside from the application 
mentioned, should be largely supporting. The patient should 
be carefully protected from any possibility of exposure or 
over-fatigue. During the menstrual period it is preferable 
that the patient should be confined to bed. The more acute 
stages having subsided, in addition to the douches and enemas 
recommended, the patient may take a hot sitz bath for fifteen 
to thirty minutes daily. With the further subsidence of the 
acute symptoms and in those cases in which it is evident that 
suppuration has not occurred, the adhesions binding down 
the ovaries and tubes may be overcome by the employment 
of pelvic massage. The structures are lifted up with one or 
two fingers within the vagina and manipulation over the ab- 
domen employed, gradually pressing the fingers in so as to 



INFLAMMATIONS. 381 

follow lines of cleavage and to lengthen the bands of adhesions 
or promote their absorption by stretching and irritation. The 
congestion and pain in chronic inflammation of the ovary may 
frequently be very greatly lessened by the administration 
of fluid extract of gelsemium, giving flve drops three times 
daily. In these conditions great prudence must be exercised 
in the administration of anodynes. A patient suffering from 
pelvic pain as a result of attacks of peritonitis, with binding 
down of the pelvic viscera, may very easily be led into the 
habit of taking morphin or opium until, instead of it simply 
being a servant, it attains the position of master, and the patient 
finds herself enslaved to a drug from which emancipation is 
very diflicult. While it may be necessary, in an acute attack, 
to administer a dose of morphin, in order to allay the violent 
pain, yet, in the majority of cases, the early and continuous 
administration of salines, associated with the application of 
the ice-bag, will be effective in arresting the severe pain, or 
at least in making it endurable. The measures which we have 
already discussed are in the line of what we have denominated 
the first aim in the treatment of lesions of the uterine appen- 
dages — that is, to maintain the functions of these organs. 

Surgical Treatment. — The surgical treatment does not neces- 
sarily discard the object which we have considered as the first 
aim in treatment, but may, indeed, assure its accomplishment, 
especially when early and efficiently established. Delay, how- 
ever, would almost certainly favor the development of conditions 
which would necessitate more serious procedures. Operative 
treatment, with a view of maintenance or restoration of func- 
tion, is known as conservative treatment. Where the sacrifice 
of the appendages is considered necessar}', in order to save 
life or insure good health, the procedure is known as a radical 
one. Conservative treatment may consist in the breaking 
up of adhesions, the reopening of the orifice of the tube, sal- 
pingostomy, or the partial resection of the tube itself, thus 
shortening it and permitting the removal of those portions 
which are prejudicial to health. (Figs. 305 and 306.) This 
procedure also comprises the resection and removal of any 
diseased portion of the ovar}', with the endeavor to retain a 
sufficient portion of the organ to insure the continuance of 
ovulation and menstruation. In chronic oophoritis with marked 
thickening of the tunica albuginea, and the development of 
small cysts in the ovary, a resection of the ovary or removal 
of the more diseased portion will frequently result in such 
metabolism as to restore the remaining portion of the ovary 
to a more normal condition. Wherever conditions will permit, 
a portion of the ovary should be retained; its retention will 
insure the continuation of menstruation and ovulation and 



382 



GYNECOLOGY. 



have a marked influence upon the general morale and nervous 
condition of the patient. The retention of the whole or a 
part of the ovary is desirable even though it may be necessary 
to remove both tubes, because it insures the continuation of 
ovulation and menstruation. This has a marked influence 



T u B t-. 




Fig. 305.— Resection of Tube. 




Fig. 306. — Operation of Resection of Tube Completed. 

Upon the nervous system of the patient. In surgical opera- 
tions we are obliged to be governed by the physical condition 
of the organs under consideration. The abdomen should not 
be opened unless palpable disease of the uterine appendages 
by physical examination can be determined. Operations for 
pain in the region of the ovary, without ovarian enlargement, 
will most frequently be attended with no favorable result. 



INFLAMMATIONS. 383 

Where the disease is extensive and ovaries and tubes have 
undergone destruction, the removal of these organs will often- 
times be the only procedure that will afford any hope for res- 
toration of the comfort and health of the patient. In sup- 
purative conditions where the ovary is also involved in the 
inflammatory process, the better plan of procedure will be 
the removal of the ovary and tube complete. In a patient 
upon whom I recently had to operate the left ovary and tube 
were so extensively involved that their removal was indicated. 
The right tube was considerably enlarged, its wall was several 
times its ordinary thickness, and the cavity of the tube contained 
pus. In this case, the left tube and ovary having been re- 
moved, the right tube was dissected out from the cornua of 
the uterus and the opening in the broad ligament was closed 
with a continuous catgut suture, thus controlling hemorrhage. 
The ovary, as it presented no marked abnormal change, was 
permitted to remain. In these cases the operation is some- 
times exceedingly difficult, as on opening the abdomen we 
will find the tube and ovary, with the fundus of the uterus, 
matted down in the pelvis in close association Avith coils of 
intestine, the omentum, and the parietal peritoneum. AVhere 
the condition is one of recent sepsis, it may sometimes be neces- 
sary to consider the advisability of removal of the uterus as 
well as of the appendages. When there is occasion to open 
the abdomen, the structure should be carefully inspected and 
examined by touch. The adhesions should be broken up and 
proper care be exercised to insure control of hemorrhage. In 
some patients, the broad ligament will be so contracted from 
the inflammatory changes that we will be unable to lift the 
ovary and tube out of the wound. In such cases the broad 
ligament should be resected with the ovary and tube. This 
may be accomplished without the application of ligature, seiz- 
ing the bleeding vessels as we proceed, and holding them with 
hemostatic forceps, after which the wound in the broad liga- 
ment can be closed with a continuous catgut suture, so intro- 
duced that each turn or second turn shall lock the preceding 
stitch, and thus secure against hemorrhage and prcA'cnt the 
broad ligament from being distorted. After operations in some 
of these more critical cases, and sometimes prior to operation, 
the patient may be very greatly benefited by the employment 
of the rest treatment, the plan of treatment introduced by 
S. Weir ]\litchell. It consists in the isolation of the patient, 
careful study of her condition, and the improvement of her 
general nutrition. The patient should be kept absolutely in 
bed; she should have her secretions corrected and her diet 
restricted, possibh' at first to milk, and, later, feeding should be 
forced. Graduated exercise should be advised, supplemented 



384 GYNECOLOGY. 

by the employment of massage and electricity. Bv these 
means the elements of the blood are restored and the patient 
gradually regains her strength and health. 

391. Pelvic Inflammation. — The term pelvic inflammation 
is a comprehensive one. It is necessary, at the outset, to 
limit it to the conditions which we intend it shall include. In- 
flammation of the individual pelvic viscera has been discussed, 
so this term will be confined to inflammation which involves the 
cellular tissue and the peritoneum. It consequently includes those 
affections described as pelvic cellulitis and pelvic peritonitis. 

These conditions have been designated as periuterine 
inflammation; by some writers of distinction, notably Virchow 
and Matthews-Duncan, the terms parametritis and perimetritis 
have been used — the former to indicate inflammation of the 
cellular tissue; the latter, of the peritoneum. These terms are 
objectionable for the following reasons : First, they are so nearly 
alike that it is difficult for the student to avoid confusion in 
their use, and the subject is rendered more difficult of com- 
prehension. Second, a difference in the anatomic relations 
of the peritoneum and cellular tissue to the uterus is implied 
which does not exist. The pelvic connective tissue and the 
pelvic peritoneum are in equally close contact with the uterus. 
It is distinctly objectionable, therefore, to consider one as an 
inflammation about the uterus and the other as an inflammation 
near it. Third, the conditions are described as associated 
with the uterus, while they may exist in all the tissues of the 
pelvis, and are not necessarily uterine in their origin. 

Careful investigation of the pathology of these conditions 
by autopsy, and their more extended study during abdominal 
procedures while in active stages of disease, have demonstrated 
how easily such erroneous views could arise. 

Bernutz and Aran, of France, many years ago demonstrated 
the true nature of pelvic inflammation, which has been abun- 
dantly conflrmed in the practice of abdominal surgery, where 
the opportunity has been afforded for comparing physical 
signs with the actual existing pathologic changes. 

392. Varieties. — Pelvic inflammation as we have described 
it is properly divided into inflammation of the cellular tissue 
(pelvic cellulitis) and inflammation of the peritoneum (pelvic 
peritonitis). It must not be understood in these definitions 
that the demarcation between these affections is sharply de- 
fined, for, in practice, we do not find inflammation confined 
to the single or specific structure. Their use indicates simply 
that the inflammation predominates in the structure named. 

393. Pelvic cellulitis, parametritis, or periuterine phlegmon, 
is an inflammation of the pelvic cellular tissue. It may be 



INFLAMMATIONS. 385 

either primary or secondary: i. e., it may have originated in 
the cellular tissue or may have reached it by extension from 
the neighboring structures. The primary inflammation is an 
acute infective disease which differs in no respect from acute 
inflammation of the connective tissue in any other portion 
of the body. Chronic, pelvic cellulitis is always a secondary 
affection; never the result of acute cellulitis. The pelvic con- 
nective tissue is not a special structure, but a portion of that 
wide system of mesoblastic connective tissue which surrounds 
the great vessels of the trunk and accompanies their branches 
from origin to termination. It is found in the pelvis, partly 
in the form of a loose areolar network, partly in the more con- 
densed form of fascia. It surrounds all the blood-vessels, 
nerves, and lymphatics, as well as the ureters, and serves as 
investing sheaths for them outside the pelvic cavity. It is 
closed off from the perineum and ischiorectal fossa by the 
pelvic fascia, a strong aponeurosis, w^hich is attached to the 
pelvic wall between the pubic bones and bodies of the ischia, 
and along that thickening of the obturator fascia known as 
the white line. It passes as a continuous layer over the levator 
ani and coccygeus muscles to the vagina in front, and to the 
rectum and coccyx behind. It closely blends with the vaginal 
orifice, behind the pubic symphysis, as the triangular liga- 
ment. Inflammatory exudations of the female genital organs 
above the vulva are situated above this strong fascia. The 
cellular area with such a boundary below has the peritoneum 
for its superior limitation. This boundary, however, is less 
abrupt, as it is continuous with the subserous connective tissue 
of the parietal peritoneum of the abdomen. With the ex- 
ception of the fundus of the uterus, it forms a layer beneath 
the entire pelvic peritoneum — both parietal and visceral. The 
so-called uterine ligaments contain more or less of it between 
their peritoneal folds, and in certain situations it is abundant; 
for instance, around the supravaginal portion of the cervix, 
and along the base of the broad ligaments and between the 
bladder and symphysis pubis. In the latter situation it con- 
tains a varying quantity of fat in its meshes. 

Its office in the pelvis, as elsewhere, is to protect and sup- 
port the other tissues, performing a passive mechanical function. 
It affords a cushion which prevents injury of the viscera (Schae- 
fer). The connective -tissue layer, between the vagina and 
peritoneum posterior to the uterus, generally does not measure 
more than J of an inch in thickness, but in pregnancy its thick- 
ness is greatly increased. During the progress of develop- 
ment of a pregnant uterus the broad ligaments are gradually 
drawn upward, until at the completion of the pregnancy they 

25 



386 GYNECOLOGY. 

lie in the iliac fossa, above the brim of the pelvis, while no peri- 
toneum dips into the lateral parts of the pelvis. The space 
thus vacated is filled with connective tissue, which during 
the later months of pregnancy is enormously increased. Freund 
describes a form of cellulitis which affects more particularly 
the fatless connective tissue, or fascia, which he calls para- 
metritis chronica atrophicans circumscriptum et diffusum. 
Cellulitis is a very common complication of pelvic peritonitis 
involving particularly the uterosacral ligaments and peritoneal 
folds. Schultze calls this parametritis posterior: uterosacral 
cellulitis is more accurate. Cicatrization of the ligaments follow- 
ing such inflammation causes traction upon the isthmus, and 
is a very common cause of dysmenorrhea and sterility. As 
a result of the contraction of the tissues, the uterus may be 
anteflexed and drawn to one side or backward, thus produc- 
ing a pathologic anteflexion. By compression of the vessels 
and nerves the uterus and ovaries may become atrophied. 
Cellulitis may exist with or without suppuration. When sup- 
puration does not occur, an exudation results in the connec- 
tive tissue, which becomes edematous, and subsequently more 
or less organized, firm, and hard, causing pressure upon the 
vessels and nerves which pass through it. The changes in 
this structure are similar to those which take place in cirrhosis 
of the liver or of the kidney. 

394. Etiology. — Primary pelvic cellulitis is always a re- 
sult of sepsis. Ready entrance for septic material is afforded 
through lacerations of the cervix uteri. These injuries may 
be caused by the use of forceps, and, if kept aseptic, readily 
heal. In the nullipara cellulitis may arise from the same causes 
as pelvic peritonitis, such as exposure to cold during men- 
struation, being then generally associated with pelvic peri- 
tonitis, and from surgical operations which open the connective 
tissue, as in the removal of large uterine polypi, affording an 
opportunity for cellulitic infection. The danger is especially 
great when the growths are expelled or removed while in a 
state of necrosis. A certain amount of lymphangitis is then 
associated, with which the lymphatic glands may be implicated. 
Cellulitis may develop from disease in the bladder. As a re- 
sult of such irritation thickening occurs in the connective tissue 
outside the bladder, which thickening passes outward and for- 
ward, and in ultimate atrophy may cause uterine displace- 
ment in the opposite direction. From the rectum, the causative 
irritation may be dysenteric. A pelvic cellulitic abscess is 
not infrequently so situated as to render it more than probable 
that the hypogastric glands are involved. Inflammation occurs 
much more rarely in the cellular tissue than in the pelvic peri- 



INFLAMMATIONS. 387 

toneum. With the advent of suppuration, an abscess follows, 
which is generally of large dimensions, although occasionally 
several abscesses may be found in close apposition. 

395. Symptoms. — In puerperal cases the cellulitis is gene- 
rally ushered in about the second or third day, with a rigor or 
chill, although it may. occasionally occur later. In nonpuer- 
peral cases the interval between infection and the first mani- 
festation of symptoms is rarely more than one or two days. 
The occurrence of the chill has produced the belief that the 
inflammation arises from exposure to cold; simultaneously with 
the chill occurs an elevation of temperature, a rapid pulse, but 
rarely pain, unless the peritoneum is involved. When suppu- 
ration occurs, the most marked symptom is the progressive 
emaciation associated with pallor or earthy sallowness of the 
skin. The skin is harsh, dry, and covered with briny scales 
from the fine desquamation. Where peritonitis is established 
and the patient is consequently ejecting a dark green fluid 
from the stomach, and is unable to retain even liquids, the 
stomach should be irrigated through the stomach-tube with 
normal salt solution. This should be repeated, if the vomiting 
returns. No food, not even water, should be allowed to enter 
the stomach. Peristalsis should be quieted by morphin, gr. 
tV' gi^^eri hypodermically, every three hours. The nutrition 
should be maintained by rectal feeding, administering normal 
salt solution, three ounces, bovinine, one ounce, every three 
or four hours, and, where necessary, hypodermoclysis or intra- 
venous injections of normal salt solution. The patient looks 
ill, loses her appetite, and suffers from marked debility and 
severe mental depression. She becomes very irritable. If the 
exudation extends to the fascia over the iliacus and psoas 
muscles, and particularly if the connective-tissue elements 
between these muscles are involved, the patient will lie upon 
her back with the leg of the affected side flexed and the thigh 
bent upon the trunk. The symptoms are those of a subacute 
form of septicemia. Pain and local signs may be so slightly 
marked as to lead to the condition being unsuspected or over- 
looked. 

396. Physical Signs. — In the early stages of an acute attack 
the physical signs are but slightly marked. All that will be 
noticed by digital examination is that the vagina is hot and its 
vessels are pulsating. In a few hours there are indications 
of an inflammatory exudate. There is a doughy sensation and 
fullness on one side of the uterus and in the iliac fossa. This 
may extend partly around the cervix, and subsequently become 
hard and indurated. If the poison has entered through a 
wound in the cervix, the latter becomes less movable. The 



388 



GYNECOLOGY. 



supravaginal tissues on the affected side are tender, more or 
less hard, and unyielding. There is a bulging at the side of 
the uterus, and the lateral fornix on that side is apparently 
obliterated. (Fig. 307.) We rarely find both sides of the 
uterus affected at the same time, but occasionally the whole 
supravaginal portion of the cervix may be embedded in a thick 
collar of indurated tissue, which more or less completely sur- 
rounds it. Generally the disease spreads laterally along the 
base of the broad ligament to the tissue beneath the reflection 
of the peritoneum on the anterior abdominal wall. When this 
occurs, a uniform hardness, or resistance, is felt in the abdominal 
wall beneath the muscles. This may assume the form of a 
broad band, from ^ of an inch to 2 inches or more in width, 




Fig. 307. — Exudation in Broad Ligament from Pelvic Cellulitis. 



which lies along the upper border of Poupart's ligament. Occa- 
sionally the exudation spreads upward and outward from above 
Poupart's ligament into the iliac fossa. This exudation may 
extend in one of two ways : (a) it follows the course of the lymph- 
atics which run from the uterus outward beneath and be- 
tween the layers of the broad ligament to the glands and lumbar 
region ; (b) by lines of cleavage in the cellular tissue of the pelvis. 
In the latter form it not infrequently passes backward, pro- 
ducing an exudation in the tissue of one or both uterosacral 
ligaments in the tissue surrounding the rectum, and lines the 
posterior pelvic wall beneath the peritoneum. In these cases 
the rectum will be felt wholly or partly surrounded by a belt of 
exudation, which forms a bridge or an arch. If suppuration 



INFLAMMATIONS. 



389 



does not occur, the exudation becomes absorbed, and in un- 
complicated cases the hardness may so far disappear as to 
leave no subsequent trace. In not a few cases pelvic cellulitis 
results in the formation of an abscess. The situation of the 
abscess and the direction in which it may be expected to extend 
depend upon the situation and the extent of the inflammatory 
exudation. If the inflammation is seated in the base of the 
broad ligament and passes forward beneath the peritoneum, 
where it is reflected on to the anterior abdominal wall, an area 
of induration may be noticed above Poupart's ligament. Sup- 
puration can be recognized by the occurrence over the indurated 
area of edema in the skin, which pits on pressure; by deep- 
seated fluctuation, especially recognized by bimanual examina- 
tion; and by the eventual pointing of the abscess a httle above 
Poupart's ligament. The 
pus can often be detected 
before it reaches the sur- 
face by passing the tip of 
the finger carefully over 
the induration, when a 
softened point will be 
recognized in the sur- 
rounding hardness. As 
we have already noticed, 
pelvic cellulitis may un- 
fortunately extend back- 
ward instead of forward, 
when, if suppuration fol- 
lows, an abscess forms 
beneath the peritoneum 
covering the back of the 
pelvis. Such an abscess 
has no direct access to 

the free surface, relief is much longer delayed, and extensive 
burrowing follows. It can extend into the iliac fossa and the 
loin, particularly when the posterior wall is the seat of the ab- 
scess. It may point at the iliac crest, or may sometimes leave 
the pelvis by the sciatic notch and follow the course of the 
sciatic or gluteal vessels. Again, it appears in Scarpa's triangle, 
having followed the side of the femoral vessels. By whatever 
route the abscess leaves the pelvis it will follow the blood- 
vessels or the ureter, which are accompanied by a prolongation 
of the connective tissue rather than by the nerves or tendons. 
When matter burrows along the psoas muscle, it comes, not 
from cellulitic abscess, but from dead bone, and this is an im- 
portant fact to keep in mind. 




Fig. 308. 



-Exudation of Cellulitis over Rec- 
tum. 



390 GYNECOLOGY. 

I saw with the late Dr. Kappes a patient who had been con- 
fined about six weeks previously, and she was suffering from 
what was apparently a subacute attack of septicemia. She 
was lying with her limbs drawn up, complaining of severe pain 
in the abdomen, extending into the groin. On examination, 
induration could be recognized extending from the left lumbar 
region into the groin. Vaginal examination disclosed the 
uterus freely movable, with no induration about it, nor in the 
pelvis, until the finger was passed well above the brim, when 
the indurated psoas muscle was recognized. On investigating 
the history of this patient it was found that she had suffered 
from a fall about the third month of pregnancy. She was 
walking on stilts in her back yard to amuse her children, when 
she tripped and fell in a sitting position. She suffered more 
or less discomfort during the entire, remainder of the pregnancy. 
An incision was made on the left side over the crest of the ilium 
and the peritoneum was pushed forward, when the tissue of the 
psoas muscle was found infiltrated with purulent material. It 
was hoped that the vent thus afforded would give the patient 
relief. She improved for a few days, when pain occurred upon 
the opposite side, where a similar condition was found. 

We not infrequently hear of cellulitic abscesses opening 
into the rectum, vagina, or bladder, but these cases, when 
considered in the light of the pathology of pelvic inflamma- 
tion, are doubtful, and are more than likely cases of intra- 
peritoneal suppuration which have originated either in dis- 
ease of the Fallopian tubes or of the ovaries. An abscess will 
usually point between the seventh and twelfth weeks. 

In discussing pelvic disease we should not overlook a peculiar 
malignant form of inflammation, mostly occurring in puer- 
peral women, in which, associated with other lesions significant 
of the virulence of the infection, multiple abscesses in the con- 
nective tissue are found. Many of these abscesses are so small 
as easily to elude detection. The condition is known as diffuse 
pelvic suppuration, and has all the characteristics of phleg- 
monous erysipelas. The tissues become edematous and of 
a livid hue. Suppurating thrombi are found in the veins and 
the lymphatics are acutely inflamed. Occasionally, the ovaries 
may be found in a state of suppuration. Associated with 
this condition are all the symptoms of acute infection in its 
most virulent form. 

397. Diagnosis. — The absence of pain not infrequently 
permits considerable progress before the existence of the con- 
dition is suspected. Puerperal women, because of the tender- 
ness of the external genitals and the presence of the lochial 
discharge, are very averse to vaginal examination. If the 



INFLAMMATIONS. 391 

puerperium pursues a normal course this aversion should be 
respected, but it can not be too strongly asserted that examina- 
tion should be made whenever symptoms of pyrexia supervene 
and the ordinary course of convalescence is interrupted. A 
temporary disturbance of temperature and of pulse-rate may 
result from such causes as constipation, excitement, and mam- 
mary engorgement. Unless such conditions can be recognized 
as provocative of the disturbance, or if the abnormal symp- 
toms are persistent, and especially if the lochia is offensive, a 
thorough examination not only of the vagina, but of the in- 
terior of the uterus, should be made. During the first ten 
days subsequent to delivery the uterus can be readily explored 
without artificial dilatation. If a portion of placental tissue 
or a decomposing blood-clot is found, it should be removed, 
and the uterine cavity should be cleansed and disinfected. 
Ordinarily the symptoms will be promptly relieved. If they 
are not, the examination will have revealed the probable cause 
of the disorder, and simultaneously will permit any swelling 
or other morbid condition of the pelvic tissues to be detected. 
A few days after the onset of the attack the physical signs 
of cellulitis will be so marked as to render the diagnosis cer- 
tain, and a laceration of the cervix or of the vagina will be 
disclosed as the probable gateway for the entrance of the in- 
fection. Occasionally the first indication of cellulitis will be 
an impaired mobility of the cervix upon one side, on which 
tenderness and swelling will be marked. Later, this inflamed 
structure becomes stiff, and passes to well-defined hardness. 
The cellulitis may be situated to one side of the cervix or may 
extend along the base of the broad ligament of the affected 
side. The lateral fornix of the vagina will be completely ob- 
literated. When the inflammation extends backward, vaginal 
examinations of the posterior wall will reveal a diffuse fullness 
and hardness on the affected side, which is still further dem- 
onstrated by rectal examination. In the rare cases in which 
the broad ligament itself is affected the diagnosis is determined 
by finding the mobility of the body of the uterus impaired, 
and a more or less flattened mass of induration upon one side, 
which is continuous with the uterus. Excepting the plane 
of tissue between the cervix uteri and the bladder, the cellular 
area of one side of the pelvis is practically shut off from that 
of the other. Hence, we flnd pelvic cellulitis is for the most 
part unilateral. The differential diagnosis of pelvic peritonitis 
will be discussed later. (See Peritonitis.) The only other 
conditions with which cellulitis can be confounded are hematoma 
of the broad ligament and myoma of the uterus. In hematoma 
there is an effusion of blood into the connective tissue, which 



392 GYNECOLOGY. 

forms a slightly movable, somewhat flattened tumor along- 
side of and continuous with the uterus. The history of the 
case and the absence of symptoms of severe illness will generally 
serve to distinguish it. It occurs suddenly, from rupture 
of a pregnant tube or of a varicose vein in the broad ligament. 
In either case the onset is marked by violent pain, faintness, 
syncope, and usually vomiting. In pregnancy of the tube 
one or two menstrual periods will have been passed, and the 
pain will be situated in the lower part of the abdomen, generally 
on one side, with irregular uterine bleeding. The effect of 
such an outpouring of blood upon the temperature and pulse 
is transient. The temperature is not elevated. If infection 
occurs, suppuration results, and the symptoms then are similar 
to those of pelvic abscess from cellulitis. Myoma can rarely 
be mistaken for cellulitis. Only in those rare cases in which 
the myoma develops laterally between the layers of the broad 
ligament and forms a more or less hard tumor directly con- 
tinuous with it is error possible. Should the myoma be com- 
plicated by a localized peritonitis, or the tumor become in- 
flamed or gangrenous, the diagnosis may be difficult. In the 
posterior wall error is scarcely probable, for large inflammatory 
exudations into the connective tissue behind the uterus are 
extremely rare. In the anterior wall the signs of cellulitic 
exudation between the bladder and the upper part of the cervix 
are well marked and characteristic. 

398. Prognosis. — The disease usually terminates in recovery, 
except in the very diffuse variety, in which it is a part of a 
general septic process. With the subsidence of the fever the 
exudation is gradually absorbed, and under favorable circum- 
stances entirely disappears in a few weeks. Cellulitis un- 
complicated by peritonitis leaves no unpleasant results, no 
adhesions nor displacements. Its existence, consequently, is 
no bar to subsequent pregnancy. If fever continues longer 
than five or six weeks, suppuration has probably resulted. 
The duration and progress of the illness will largely depend 
upon the direction the pus takes. Generally it points above 
Poupart's ligament, where it can be easily and satisfactorily 
opened. Such cases invariably do well. In the rare cases 
when it occurs at the back of the pelvis, pus is longer in reach- 
ing the surface, and may burrow in different directions. Such 
cases often last a long time, and are likely to be complicated 
by extension to the peritoneum. When resolution and the 
absorption of the inflammatory processes are slow, the exudate 
will become organized, and cause cicatricial contraction and 
resulting displacement of the uterus. Such contractions also 
lead to atrophy of the uterus and ovaries. The obstruction 



INFLAMMATIONS. 393 

of the circulation produces localized congestion, and even 
inflammation, and causes disturbances of menstruation, such 
as menorrhagia and dysmenorrhea, and sterility. It is neces- 
sary, then, to be guarded in our promises of complete recovery. 
399. Treatment. — A description of the disease and of its 
causes emphasizes the importance of preventive treatment. 
This consists in careful attention to the principles of asepsis 
or surgical cleanliness in all midwifery cases and in surgical 
manipulations. If freedom from infection could be insured, 
pelvic cellulitis would disappear. When the disease is once 
developed, medication, either internal or external, has but 
little influence. The most important indication is to avoid 
doing the patient harm. Particular care should be exercised 
in the administration of opium and antipyretics. The former 
agent is generally given as a matter of routine. Opium adds 
to the disturbance of the already obstructed digestive functions 
and aggravates one of the difficulties which it is important 
to obviate: viz., constipation. Opium or morphin should 
be given only in cases complicated by peritonitis, in which it is 
absolutely necessary to aft'ord relief. Similarly, antipyretics 
should be reserved for the rare occasions when the temperature 
is so high as to constitute in itself a source of danger. A simple 
saline mixture, potassium citrate, or small, frequently repeated 
doses of magnesium sulphate should be given until the bowels 
are freely evacuated. Care should be exercised to avoid fecal 
accumulation. The question of feeding is of equal impor- 
tance: farinaceous diet in the acute stages, with meat, eggs, 
and easily digested food in the later period of the disease. The 
tendency to emaciation calls for generous feeding. In the 
early stages of the inflammation an ice-bag over the abdomen 
will limit the congestion and the amount of inflammatory 
exudate. When the ice-bag is uncomfortable or causes dis- 
tress, hot fomentations should be applied. Hot vaginal douches, 
at a temperature of from iio° F. to 115° F., are advocated 
by Emmet, although the influence they exert is doubtful. When 
pus forms, the case should be dealt with according to recog- 
nized surgical principles. The abscess should be opened as 
soon as fluctuation is detected or there is the faintest indication 
of pointing, and drainage should be instituted for a few days. 
If the abscess points in the vagina, it must be opened there. 
Most of the fluctuating swellings felt through the vaginal roof 
are not cellulitic abscesses, but come from an entirely difterent 
direction. While it is not generally recognized as the proper 
plan of treatment, yet, without question, the course of an abscess 
can be shortened by making an incision into the infected cellular 
tissue through the vagina as soon as the swelling about the 



394 GYNECOLOGY. 

uterus can be recognized. The infected area should be broken 
into with the finger, and a gauze drain inserted which will 
afford vent for the discharge. The drainage thus secured 
will frequently obviate the occurrence and danger of suppura- 
tion and prevent the extension of inflammation to the pelvic 
peritoneum. If the patient lies with the thigh flexed on the 
body, the limb should be exercised by lifting the foot with 
the hand under the heel two or three times a day sufficiently 
to straighten the knee. This will prevent permanent contrac- 
tion and stiffening of the joint. 

Chronic pelvic cellulitis, as already asserted, does not exist 
as an independent affection or as a sequel of the acute disease. 
It not infrequently follows purulent salpingitis or other intra- 
pelvic suppurative inflammation, and involves only the parts 
immediately contiguous to the inflamed structures. The indura- 
tion which it causes, for a time, of course, introduces an ele- 
ment of obscurity into the diagnosis of deep-seated inflam- 
matory lesions of the pelvis. It is rarely attended with cellulitic 
abscess, and is characterized chiefly by edema and small-cell 
infiltration of the connective tissue. Its absorption and the 
mobility of the uterus may be promoted by the practice of 
pelvic massage. (Section 169.) When cellulitis has existed 
sufficiently long to result in atrophy of the uterus or ovary, 
treatment exerts but little effect. 

400. Pelvic peritonitis, perimetritis, perisalpingitis, or peri- 
oophoritis, is an inflammation of the peritoneum situated with- 
in the pelvis. It occurs much more frequently than pelvic 
cellulitis; indeed, more frequently than any other form of in- 
flammatory disease within the pelvis. In the great majority 
of cases it is an infective process, due either to the presence 
of micro-organisms or to the effect of their chemic products. 
In the main its action may be regarded as beneficial, it being 
one of nature's efforts to resist or to do battle with the invad- 
ing foe by erecting barriers around the diseased area. These 
barriers serve to narrow or to confine the field of invasion, and 
shield the neighboring structures from damage. Treves asserts 
that the purpose of peritonitis is to save and not to destroy 
life. Unfortunately, the poison may be so virulent or may 
exist in so large a quantity that we are neither able to limit 
nor to guide the inflammatory process to a successful issue. 

401. Etiology.— Pelvic peritonitis probably never occurs 
as a primary disease, but always as a complication of a pre- 
existing disorder. Occasionally, however, it is the first recog- 
nized expression of such disease. The symptoms of peritonitis 
are so severe that attention is at once aroused, while the con- 
dition from which it originated may have been so insidious 



INFLAMMATIONS. 395 

as to have been overlooked. From want of knowledge, then, 
of the previous condition we are often compelled to ignore the 
exciting condition, and to say that the patient suffers from 
pelvic peritonitis. Is it surprising that the original condition 
was formerly unrecognized and the disease denominated idio- 
pathic peritonitis, the result of a slight injury or of exposure 
to cold? It is true there are still cases in which we are un- 
able to discover the preexisting disease, but the number of 
such cases has become less and less frequent, and failure to 
determine the cause of pelvic peritonitis is the result of de- 
fective observation and of want of knowledge. 

The most frequent cause is sepsis; next, gonorrheal infection. 
The micro-organisms principally concerned in the develop- 
ment of infection are the streptococcus, the staphylococcus, 
the gonococcus, the bacillus coli communis, and the bacillus 
tuberculosis. The propagation of these infectious micro-organ- 
isms is favored by parturition, abortion, instrumental ex- 
amination, and surgical interference. Other causes are in- 
flammations of the appendix, intestinal perforations, abdominal 
lesions, rupture of an ectopic gestation, hematocele, ovarian 
abscess, or hematoma, and malignant disease. 

Infection generally reaches the peritoneum in one of three 
ways: first, by the continuous mucous membrane through 
the uterine cavity and tubes; second, by the blood-vessels; 
third, by the lymphatics. 

Ttibal disease is the most common cause of pelvic peri- 
tonitis, and should receive first consideration. The mucous 
membrane of the Fallopian tube is continuous with that of 
the uterus, and at its abdominal end opens into the peritoneal 
cavity. 

The continuity of the tubal mucous membrane with that of 
the uterus and vagina subjects it to continual danger of in- 
fection. The tendency of every acute infective endometritis, 
whether septic, gonorrheal, or tubercular, is to extend to and 
involve the tube. The relation of the tubal mucous mem- 
brane to the peritoneum, in infection of the former, favors 
its extension to the latter. This risk is further aggravated 
by the anatomic position of the tube in woman. No other 
mucous membrane is similarly situated. The uterine cavity, 
when inflamed, naturally drains into the vagina through the 
external os; but the tube has its most constricted portion to- 
ward the uterus, where the lumen of the canal is but large 
enough to permit the passage of a bristle. A very slight amount 
of swelling will be sufficient to close the uterine end, when 
the only outlet of the tube is into the peritoneum. The ab- 
sence of a suitable outlet for morbid secretions of the tube 



396 GYNECOLOGY. 

and the continuity of its mucous membrane with the perito- 
neum render inflammatory affections of the canal of especial 
importance and make pelvic peritonitis so frequent a conse- 
quence of salpingitis. 

A prompt result of peritonitis is closure of the abdominal 
ostium of the tube by adhesions or by inflammatory changes 
in the fimbriag. The tube is then filled with retained secretion, 
and becomes the center for an inflammatory process which 
extends through the wall to the neighboring tissues, especially 
the peritoneum. If this extension is not an immediate occur- 
rence, the tube is subject to frequently recurring inflammatory 
attacks from slight causes. When the retained secretion 
consists of pus, the liability to recurring attacks of pelvic peri- 
tonitis is much greater than when the accumulation is serous 
or mucopurulent, to which liability is added the danger of 
ulceration of the tube-wall and the possibility of pus escap- 
ing into the peritoneal cavity by perforation. Frequently 
the ovary becomes infected from the tube, suppurates, and 
affords a fresh source of danger. Both inflamed tube and 
ovary may act as sources of peritonitis, but sometimes the tube, 
after infecting the ovary, recovers and is no longer a focus 
for infection. Infection of the ovary is very prone to occur 
when the latter has been the site of cystic disease or when a 
Graafian follicle has recently ruptured. The most frequent 
mode of infection is through a cyst-w^all which in places has 
become adherent to a diseased tube. Sometimes the infection 
occurs through an ulcerative process which permits the tubal 
contents to enter the cyst suddenly by perforation of the cyst- 
wall. Tubo-ovarian abscess is thus explained. Such an in- 
fection may produce an attack of peritonitis more violent 
than any preceding. 

A more alarming attack of peritonitis is engendered by the 
escape, through ulceration, of the contents of a suppurating 
tube or ovary into the peritoneal cavity. Fortunately, such an 
occurrence is rare. The thinned wall of such a collection is a 
menace which places nature upon her guard and stimulates 
her to form adhesive barriers which will limit the space into 
which the rupture occurs and favors the formation of an intra- 
peritoneal abscess. Such an abscess may rapidly enlarge, 
and, if the patient survives, may burst into one of the neighbor- 
ing viscera, into the peritoneal cavity, or externally, accord- 
ing to its situation. Suppuration of an ovarian cyst may be 
independent of infection through the tube; occasionally, it 
more than probably occurs from the proximity of an inflamed 
growth about the rectum or intestine. The cyst is more vulner- 
able to such infection when it has been exposed to injury, or 
subjected to bruising, as in labor. 



INFLAMMATIONS. 397 

Peritonitis may be favored by twisting of the pedicle of 
an ovarian cyst. This accident can result in strangulation, 
intracystic hemorrhage, inflammation, or necrosis of the growth, 
according to the amount of strangulation. The accident is 
particularly prone to occur during parturition. 

The presence of puerperal sepsis should be regarded as de- 
manding careful investigation. New pelvic growths, by their 
mere presence, may engender peritonitis. This is common 
in ovarian tumor. The tumor varies greatly in the prob- 
ability of its producing peritonitis. Uterine fibromata may 
attain a large size without adhesions unless degenerative pro- 
cesses set in, while a papilloma of the ovary or tube, dermoids, 
and malignant diseases are usually associated with extensive 
peritonitis. 

Severe septicemia may follow abortion, parturition, or sur- 
gical manipulations, and, instead of being confined to the uterine 
mucous membrane, can at once be carried by blood-vessels 
or lymphatics to the peritoneum, and generate a diffuse septic 
infection in the pelvis. Such a peritonitis may become localized 
in the pelvis or may rapidly prove fatal by its extension to 
the general peritoneum. 

Clinical experience has demonstrated that injury alone 
will cause peritonitis only when the hand or instrument in- 
flicting the injury is surgically unclean. The truth of this 
assertion is illustrated by the infrequency with which exten- 
sive operative manipulation within the peritoneal cavity is 
followed by inflammation, and by the frequent attacks of 
virulent and fatal peritonitis following slight injuries in eft'orts 
to produce abortion. It is, without question, a mere prob- 
lem of infection. The operator in the latter is usually ignorant 
or reckless. 

Complications during parturition may cause peritonitis. 
The shape and size of the normal pelvis is adapted to the pas- 
sage of the normally constructed child at full term, and is with- 
out extra accommodation. Any encroachment upon the pelvis 
by tumor, growth, or malformation, affords an obstacle which 
renders passage through the canal possible only at the expense 
of injury or bruising, which may result in loss of vitality of 
tissue or growth, and thus render the structiures more suscep- 
tible to the influence of pathogenic micro-organisms. 

Pelvic cellulitis, it has been said, is generally secondary, 
but still it may precede the peritonitis. This is particularly 
true of suppuration. 

Pelvic hematocele is a source of peritoneal inflammation. 
The irritation induced by the blood diffused into the perito- 
neal cavity causes exudation and adhesive peritonitis. The 



398 GYNECOLOGY. 

blood-serum may be roofed in beneath adherent omentum 
and coils of intestine, when the peritonitis limits effusion and 
promotes its subsequent absorption. 

Inflammation of the vermiform appendix, or appendicitis, 
is a not infrequent cause of pelvic peritonitis. Its normal 
situation is in the right inguinal region, just above the brim 
of the pelvis, but instances have occurred in which it was found 
lying within the pelvis. In right-sided inflammation of the 
pelvic peritoneum an inflamed appendix should always be 
regarded as a possible source for the infection. An abscess 
formation may follow, which will fill up Douglas' pouch. In 
many cases it is difficult to determine whether the appendix 
or the right tube is the original source of infection. 

402. Pathologic Anatomy. — Infiammation of the peritoneum 
may be serous, adhesive, or suppurative, and acute or chronic. 
As it most frequently originates from infection through the 
tubes, the tubes and ovaries are, therefore, implicated. It 
begins as a congestion or hyperemia of the serous surface, 
with cloudy swelling of the endothelium. The membrane, 
instead of being smooth and glistening, becomes dull, dry, 
clouded, and slightly roughened with plastic lymph, which 
is poured out between its adjacent surfaces. The adhesions 
thus produced are its most characteristic feature. In recur- 
rent attacks we find additional adhesions. Serum exudation 
becomes encapsulated, is found in the meshes of the connective 
tissue, may fill the culdesac or pelvis, posterior to the uterus, 
or it may be encysted to one side. Such collections may simu- 
late a cyst. When the exudation thrown out is considerable, 
it may form a distinct coating, which may be peeled from the 
surface of the peritoneum. These lymph coagula are also 
found floating in the serum, and, as the fluid becomes absorbed, 
this coating stiffens the peritoneum, and, with the induration 
in the subjacent cellular tissue, causes the hardness which is 
one of the striking characteristics of chronic pelvic peritonitis. 

These indications of inflammation are usually most strongly 
marked about the fimbriated ends of the Fallopian tube, and 
diminish as they pass from it. When the infiammation has 
originated from some other cause, such as an infiamed appen- 
dix, the alteration and adhesions are most dense at the seat 
of origin. Thus, a Fallopian tube, when it becomes inflamed 
and increases in weight, drops from its original position, so 
that it is found upon the floor of the lateral fossa of the pelvis, 
in the pouch of Douglas, or adherent by its fimbriated end 
to the ovary or to the side of the pelvis. Occasionally, the 
two tubes meet, and the distal ends become adherent to each 
other behind the uterus. At other points the direction of the 



INFLAMMATIONS. 399 

tube may differ in two sides of the body. One side is bent 
like a horseshoe, while the other terminates against the lateral 
wall of the pelvis, to which it is adherent by its abdominal 
end. If the uterus is lifted out of the pelvis by pregnancy, 
the tube may be found situated above the brim, close to the 
border of the psoas muscle. The ovary is generally found 
implicated in the mass of inflammation which has extended 
from the tube. When this inflammation has existed for some 
time, we generally find the ovary in a cystic state, and con- 
siderably enlarged. These changes result from the effect of 
the surrounding peritonitis. 

In chronic cases the peritoneum, in places, is lifted up by 
circumscribed collections of serous fluid in its meshes. These 
swellings vary in size from a pea to a large orange. They 
possess no pathologic importance, but often increase the diffi- 
culty in arriving at an accurate diagnosis. A mass formed 
by an inflamed tube, ovary, and broad ligament not infre- 
quently is found adherent to the posterior pelvic wall and rectum. 
Sometimes a coil of intestine or a portion of omentum may 
intervene, when the parts are so entangled in an extensive 
mass of exudation as to cause great difflculty in outlining and 
determining their relations. The body of the uterus is envel- 
oped in a mass of adhesions or is completely free. When 
the lesion from Avhich the peritonitis has originated is puru- 
lent, peritonitis is also apt to be purulent, and, instead of an 
accumulation of serum, pus or intrapelvic abscesses are found. 
Occasionally, suppurative peritonitis exists. The latter occurs 
only in cases of exceptional virulence, or from sudden bursting 
into the peritoneal cavity of a pus collection which was situated 
in an ovary or tube. Intraperitoneal abscesses may be single 
or multiple. They generally originate by the rupture of a 
suppurating Fallopian tube, or by the discharge through its 
abdominal ostium of pus into Douglas' pouch or into a space 
bounded by adhesions. Both tubes may thus discharge into 
a common receptacle, which is most generally Douglas' pouch. 
A tense, fluctuating swelling is formed, easily felt through 
the depressed vaginal roof, which, by pressure against the 
intestine, causes more or less obstruction. Purulent inflam- 
mation of the tube leads early to closure of the abdominal 
ostium, w^hen the pus is conflned within the tube, and forms 
what is known as a pyosalpinx. An intraperitoneal abscess 
or general peritoneal infection may then be induced by in- 
fection through the tubal wall, or by the bursting of the pyo- 
salpinx from ulceration within, or by the spread of infective 
processes to the ovary, causing it to suppurate. 

An intraperitoneal abscess walled in by adherent viscera 



400 GYNECOLOGY. 

may run an acute course or may be retained for a long time, 
causing few, if any, indications of its presence. One of two 
things is likely to occur, however: either the abscess gradually 
dries up and disappears, or its walls undergo ulceration and 
its contents escape into the bowel — usually the rectum, sig- 
moid flexure, or colon — or into the vagina, the bladder, the 
general cavity of the peritoneum, or some part of the abdom- 
inal wall. The most frequent exit is through the intestine. 
The other routes are exceptional. Such abscesses differ very 
markedly from cellulitic abscesses, and will quickly disappear 
when they have once found an outlet. The latter discharge 
their contents imperfectly. A troublesome sinus remains for 
years, producing serious ill health. Among the secondary 
changes resulting when salpingitis is unilateral is an exten- 
sion of the peritonitis to the other side of the pelvis, involv- 
ing the healthy uterine appendages in a mass of adhesions, 
which complicate the function of both tube and ovary. Such 
a condition may be followed by hydrosalpinx. 

Hydrosalpinx may result as a sequal of salpingitis, but 
is rare. 

Effusion of blood within the tube (hematosalpinx) in the 
great majority of cases arises as a consequence of tubal ges- 
tation, but occasionally may be independent of the latter. 

403. Symptoms. — The first characteristic of acute pelvic 
peritonitis is pain in the lower part of the abdomen, which 
is sudden in its onset. For a few hours it is extremely severe, 
associated with fever, with an elevation of temperature, with 
increased rapidity of pulse, and often with vomiting. An early 
symptom is more or less intestinal distention, which may be 
general or localized. Following the acute pain, movement 
is attended with great suffering, because of the tender, inflamed 
parts, and the patient is generally obliged to remain in bed 
for a length of time dependent upon the severity of the attack. 
Rigors are infrequent, unless the condition is part of a diffuse 
septic inflammation, or the result of intraperitoneal rupture 
of a pyosalpinx or a suppurating ovary. Constipation is usual. 
Pain precedes defecation and micturition, owing to the con- 
tiguity of the inflamed part to the rectum or bladder. Not 
infrequently the pain is greater at the completion of micturition. 
The patient generally assumes the recumbent posture, with 
the limbs flexed, and guards the abdomen against the pressure 
of clothing or contact with the hand. In subacute or chronic 
cases there is pain in the back and inability to undergo physical 
exertion. Menstruation is more profuse than normal, often 
painful. Very trifling causes will result in recurrence of the 
attacks. This is particularly true when the chronic pelvic 



INFLAMMATIONS. 401 

peritonitis is maintained by the presence of pelvic suppura- 
tion. Recurrence of pain and abdominal tenderness are more 
reliable indications of the presence of pus than is elevation 
of temperature. Not infrequently a large quantity of pus 
may be found in the pelvis of the patient, who has either a 
normal or a subnormal temperature. Patients in whom ex- 
tensive suppuration exists are found emaciated, and incapac- 
itated for work or exercise. In the worst cases the patient 
will be bedridden. The amount of suffering depends upon 
the nature and extent of the disease and upon the social posi- 
tion of the patient; in other words, upon the demands that 
are made upon her activity. In an acute attack the abdominal 
muscles are kept rigid over the affected parts. This rigidity 
is due to muscular contraction, and is beyond the control of 
the patient. Occasionally, by abdominal palpation a definite 
swelling can be recognized. This is particularly true when 
the mass is situated above the brim of the pelvis, has attained 
a large size, or presents an encysted exudation of serum or 
pus in front of the uterus or against the pelvic wall. Occasion- 
ally, the abdominal enlargement will be due to the presence 
of serous fluid. When depression of the vaginal roof occurs, 
it will not be lateral, but central, because the accumulation 
of effusion, serous or purulent, is in Douglas' pouch. Upon 
vaginal examination the parts may be very tender, with a 
sense of resistance, or the uterus is pushed forward. After 
subsidence of the acute symptoms a careful bimanual examina- 
tion, for which an anesthetic may be required, will often re- 
veal in the posterior fossa of the pelvis the presence of a fixed, 
irregular, tender swelling. This begins at the uterine cornu 
as a cylindric body, equal in thickness to a lead-pencil; it may 
be rolled between the fingers, but may suddenly become thicker 
a short distance externally; it curves itself, may completely 
reverse its direction, and finally ends behind the cervix uteri 
in the pouch of Douglas. A Fallopian tube can be adherent 
to the ovary, which is embraced within the concavity of its 
curve, and surrounded on all sides by a thickened adherent 
peritoneum. The uterus is not always displaced, but is often 
found retro verted or retroflexed, and adherent in its abnormal 
position. Again, it may be pushed forward by a mass of effusion 
in Douglas' pouch. The shape and consistence of the swelling 
vary in different cases, as the tube may be soft, sausage-shaped, 
particularly when its abdominal ostium is occluded, or it may 
be distended mostly at the outer end, which gives it the shape 
of a retort. Occasionally it is irregular, distended from sac- 
culation, thrown into knuckles or prominences, bent upon 
itself, with sausage -like convolutions produced by intervening 

26 



402 GYNECOLOGY. 

constrictions. Its consistence depends upon the extent to 
which the walls of the tubes have become thickened and upon 
the induration of the surrounding peritoneum. 

404. Diagnosis. — Peritonitis may be confounded with hema- 
tocele and cellulitis. Pelvic hematocele is readily distinguished 
by its clinical history, slight febrile disturbance, history of 
a possible tubal gestation, severe pain attending the rupture 
of the latter, and the subsequent bloody discharge from the 
uterus. The distinguishing features between peritonitis and 
cellulitis are as follows: 

Peritonitis. Cellulitis. 

1. Inflammation is chiefly confined to i. Inflammation principally affects 

the pelvic peritoneum. the pelvic cellular tissue, 

2. Inflammation is bilateral. 2, Inflammation is unilateral. 

Differential Diagnosis. — 

Peritonitis. Cellulitis. 

1. Its onset is sudden, with severe i. Its onset is insidious, pain not 

pain. marked. 

2. Both legs are drawn up. 2. One leg is drawn up. 

3. A firm, flat effusion surrounds the 3. A firm effusion bulges usually into 

uterus or a mesial bulging is pro- the fornix of the one side ; the 

duced by serous effusion in cervix is apparently shortened on 

Douglas' pouch; the vaginal por- the affected side, 
tion of the cervix is of normal 
length. 

4. The inflammation does not extend 4. Exudation, or pus, spreads in 

along the round ligament and definite directions, and is usually 

iliac fossa; but it may affect the localized, 
entire peritoneum. 

5. The uterus is displaced forward or 5. The uterus is displaced to one 

backward. side. 

6. Vomiting is frequent. 6. Vomiting is infrequent. 

405. Prognosis. — The mortality of peritonitis is much higher 
than that of cellulitis. Even when the patient recovers, the 
after-effects are more troublesome, and not infrequently the 
sequels are sufficiently serious to entail a life of chronic in- 
validism. The disease from which the peritonitis originates 
remains after the subsidence of the acute attack, and con- 
stitutes a focus from which subsequent attacks are likely to 
result, either from changes in the diseased tissues or from ex- 
ternal agencies. Recurring attacks of peritonitis are much 
more likely to occur when associated with the presence of pus, 
either in the form of pyosalpinx, suppurating ovary, or intra- 
peritoneal abscess. The damage done to the uterus, ovaries, 
and Fallopian tubes, particularly to the latter, by the obstruc- 
tion of the abdominal ostium necessarily causes sterility. If 
the gradual absorption of the morbid products permits the 
occurrence of conception, the continuation of pregnancy to 



INFLAMMATIONS. 



403 







^ 






^-i'" 



iV-i'V^X; 






full term may be rendered impossible by the inability of the 
organ, from extensive adhesions, to reach its normal extension. 
It is not possible, however, to say that pregnancy can not 
occur, for experience has demonstrated that even after the 
most virulent peritonitis the parts may so recover themselves 
as to permit of a subsequent conception. The discreet prac- 
titioner will consequently hesitate positively to assert that 
the patient can not give birth to children. Another effect of 
pelvic peritonitis is interference with the normal action of the 
intestinal canal. 

The final termination must depend upon the condition of 
the individual patient. 

406. Treatment. — 
The first and most 
important aim of treat- 
ment is prevention. The 
large majority of non- 
puerperal cases of pel- 
vic peritonitis originate 
from a pre-existing gon- 
orrheal salpingitis ; con- 
sequently, the treat- 
ment should consist in 
the arrest of the infec- 
tion before it has ex- 
tended beyond the 
reach of local applica- 
tion. Unfortunately, 
gonorrhea is ver}^ fre- 
quently regarded as an 
unimportant affection, 
although it probably 
destroys the health of 
a larger number of 
women than does the 

much more dreaded poison of syphiHs. The earlier symptoms 
of the disease usually pass unregarded. They are attended with 
but little pain — often none, if the urethra is "^not involved — and 
the significance of the purulent discharge is not reaHzed. I\Iedi- 
cal advice, consequently, is unsought until the infection has pro- 
duced serious results or has inflicted lifelong damage. Even 
when advice is obtained, the disease is seldom regarded seriously, 
and vigorous treatment is not employed. A purulent vaginal 
discharge in a recently married woman should always be re- 
garded with grave suspicion, and its treatment should be under- 
taken with a due sense of responsibility. 




Fig. 309. — -Induration from Peritonitis. 



404 



GYNECOLOGY. 



The object of treatment should be to prevent the extension 
of disease to the tube and the development of septic salpingitis. 
Its occurrence means a focus for the continuous distribution of 
infection and a cause for frequently recurring attacks of peri- 
toneal inflammation. Such invasion, as would naturally be 
inferred, is a frequent consequence of gonorrhea, but its avoid- 
ance requires rigid adherence to the rules of aseptic surgery 
and midwifery in the management of abortion, parturition, 
and surgical manipulation. Care should be exercised in the 
examination of patients, and particularly when such investigation 
is to be intrauterine. 

When the patient has once been the victim of pelvic peri- 
tonitis, it is extremely important that all causes likely to pro- 
voke a relapse should be avoided. She should be careful in 
her dress, should not be exposed to cold or damp, especially 
during her menstrual period, and exhausting exercise or over- 
fatigue should be guarded against. Prolonged standing is 
as disastrous as excessive exercise. She should be cautioned 




Fig. 310. — Induration from Pelvic Cellulitis. 



to secure sufficient rest, and the state of her bowels should be 
carefully watched. Intestinal adhesions naturally increase the 
tendency to habitual constipation. The fecal accumulation 
favors the development and migration through the coats of 
the intestines of pathogenic micro-organisms, so the tendency 
to constipation should be overcome by suitable aperients, or 
by enemata of glycerin or of soap and water. The medical 
treatment is very similar to that employed in pelvic cellulitis, 
with the exception that opium and its derivatives may be neces- 
sary in some cases of peritonitis. Their administration, how- 
ever, should be regarded as an unavoidable evil, and only small 
doses should be given, and these discontinued as early as pos- 
sible. Constipation should be prevented by appropriate aperi- 
ents or enemata, or both. Accumulation of scybala is more 
harmful than active purgation. During an acute attack the 
patient should rest in bed, and the diet should be restricted 
to liquid or easily digested food at regular intervals. The 
pain should be relieved by the application of the ice-bag, or, 



IXFLAAIMATIONS. 405 

if this is uncomfortable, by hot fomentations. Intestinal dis- 
tention is relieved by the use of enemata. The patient will 
probably be tormented by thirst and by the desire for ice or 
to drink effervescent waters. She will find much greater re- 
lief from frequent sipping of hot water. Ice should be avoided, 
as, when once employed, it increases the thirst, and the patient 
will be constantly demanding it, with the result, if granted, 
that the mouth and tongue will soon suffer from a severe attack 
of glossitis. If the enemata fail to give relief, an aperient 
should be administered — doses of calomel, castor oil, or, what 
is more efficient, sulphate of magnesia. The latter may be 
given in one- to two-dram doses, dissolved in syrup of ginger 
and cinnamon-water, ever}^ two or three hours until the bowels 
are freely evacuated; subsequently three or four times a day, 
as the condition may demand. A palatable method of ad- 
ministering sulphate of magnesia is to give a teaspoonful of a 
saturated solution, which has been strained, mixed with an equal 
quantity of lemon-juice, and given while eft'ervescing. The 
state of the pulse is a more correct guide to the condition of 
the patient than the temperature, and will indicate the need 
for stimulants. If the pulse shows signs of flagging, becomes 
thin, feeble, and intermittent, brandy or whisky should be 
given in regular doses, diluted with five or six times the quan- 
tity of water, its eft'ect being carefully watched, the dose to be 
increased or diminished according to its influence. Stimulants 
should not be allowed to take the place of food. The indications 
of collapse — coldness of the extremities, sunken features, flagging 
pulse, subnormal temperature — should be further combated 
by the application of external heat and by the hypodermic 
injection of strychnin and atropin or digitalin. The intensely 
depressing eft'ect of intestinal distention should be kept in mind, 
and this condition should be relieved by the use of enemata 
or by the introduction of a soft -rubber rectal tube with the 
patient turned upon the side. Xot infrequently, as suggested 
by Keith, an injection of quinin, gr. vj, whisky, f.^ss, and water, 
foij, repeated every hour until three doses have been given, 
stimulates the nerve centers and increases peristalsis. The 
most effective enema is an ounce of powdered alum dissolved 
in a quart of hot water. This is best given with the patient in 
the position with the hips elevated. This enema promotes 
peristalsis, and, consequently, is of service in tympanites. 
Where peritonitis is established and the patient is ejecting a 
dark green fluid from the stomach, and is unable to retain even 
liquids, the stomach should be irrigated through the stomach- 
tube with a normal salt solution. This should be repeated if 
the vomiting returns. No food, not even water, should be 



406 GYNECOLOGY. 

allowed to enter the stomach. Peristalsis should be quieted 
by morphin, gr.y^-Q, given hypodermically every three hours. 
The nutrition should be maintained by rectal feeding, admin- 
istering normal salt solution three ounces, bovinine one ounce, 
every three or four hours, and, where necessary, hypoder- 
mocleisis or intravenous injections of normal salt solution can 
be employed. 

The occurrence of peritonitis should lead to a careful examina- 
tion of the pelvis, and any indication of tenseness in Douglas' 
pouch or about the cervix should be considered an indication 
for immediate vaginal incision to break up the tissue and per- 
mit the fluid to escape. The opening should be kept patulous 
by the introduction of a gauze drain. Such a course will not 
infrequently arrest or limit the progress of the inflammation. 
The mere removal of the tension affords great relief. If an 
intraperitoneal abscess exists, such interference not only affords 
relief, but may anticipate its bursting into the rectum and 
the establishment of a troublesome sinus. Unless such con- 
ditions can be determined, however, it is wiser to defer sur- 
gical intervention until the acute symptoms have subsided. 
If the attack is the first the patient has had, and the swelling 
is so slight as to indicate a possibility of a probable nonpurulent 
inflammation, operative interference should not be advised. 
If the patient has repeatedly had similar attacks, and swell- 
ing of such a size is found as to render it probable that in its 
midst there is an occluded, distended Fallopian tube or an 
enlarged, cystic ovary, operation should be urged. Such a 
mass, with the recurring attacks, almost positively indicates 
the presence of pus; and where pus is present, surgery is ab- 
solutely indicated. It is impossible, of course, to lay down 
positive rules: every case must be decided upon its merits. 
A woman from the laboring class can not afford to spend as 
much time in invalidism as a woman in better circumstances. 

When operation has been decided upon as necessary, the 
method of procedure still remains undetermined. Abdominal 
section being the older and more generally adopted procedure, 
it will be first described. For the preparation of the patient 
see Section 124. The patient is placed upon the operating 
table, preferably one by which the Trendelenburg posture 
can be secured, and an incision from 2^ to 3 inches long is made 
in the median line, beginning an inch above the symphysis pubis. 
The operator must remember the possibility of adhesions be- 
tween the intestines, the omentum, and the anterior abdominal 
parietes, and should proceed carefully as he approaches the 
peritoneal cavity. Generally the omentum is adherent to the 
mass in the pelvis, over the surface of the uterus, the tubes, 



INFLAMMATIONS. 407 

or the ovaries. The first step is to separate these adhesions, 
and to free the omentum and any coil of intestine which may 
be adherent. The omentum and intestines are drawn upAvard 
to expose the matted contents of the pelvis behind them. When 
the patient is lying flat, we have to be guided almost entirely 
by the sense of touch. • In the Trendelenburg posture we are 
aided in our manipulations by sight. Following the fundus 
of the uterus as a guide, the operator endeavors with the tips 
of the first two fingers to enucleate the diseased uterine appen- 
dages from their adherent surroundings. The fundus of the 
uterus may be free or implicated in the adherent mass. In 
the latter case its identification may be exceedingly difficult, 
rendering it necessary for an assistant to pass one or tw^o fingers 
into the vagina to elevate the uterus by pressure against the 
cervix. The fundus is thus identified. The affected tube, 
on one side, is traced out from the uterine cornu and made 
to serve as a guide when searching for planes of adhesion. If 
it turns backward and becomes lost in the adherent mass, 
the safest way is to keep the fingers close to the posterior sur- 
face of the uterus, and to trace the adherent mass downward 
to Douglas' pouch. In breaking up the adhesions it is neces- 
sary to separate the mass from the walls of the bowel, includ- 
ing the anterior wall of the rectum. It is often advisable to 
have an assistant pass his forefinger into the rectum, partly 
to facilitate the separation by steadying the bowel, partly to 
ascertain where the bowel is and whether the manipulation is 
in dangerous proximity to it. The separation of these adhesions 
in Douglas' pouch is generally the most difficult part of the 
operation. Indeed, I know of no operation more difficult than 
to have to break up adhesions which have existed for a long 
time between knuckles of intestine and the fundus of the uterus 
or the ovaries and tubes. The separation is to be continued 
posteriorly from below upward. When the mass has been 
cleared from its posterior and inferior attachments to the uterus 
and to the uterine appendages of the opposite side, there still 
remain adhesions to the back of the broad ligament, which 
has become more or less folded over the diseased parts, and 
forms a deep, concave surface on its posterior aspect. This 
concave surface has to be unfolded in order to permit the mass 
to be brought into view and the broad ligament below it to be 
trc^nsfixed. This separation can be accomplished by working 
from below upward, and should be continued until the ovary 
and tube remain attached to the uterus and broad ligament 
by their anatomic connections only. The pedicle is then tied 
in the same manner as in the removal of the normal ovary and 
tube for the relief of myoma. The appendages on the opposite 



408 



GYNECOLOGY 



side are examined, and are removed or left, according to their 
condition. If merely adherent, the operator may content 
himself by simply separating the adhesions. 

During such manipulation it is not infrequent to find an 
escape of pus, which may be independent of any fault of the 
operator. It is often difficult to accomplish without rupture 
the separation of adhesions around the ostium of a suppurating 
tube or the enucleation of a suppurating and adherent ovary 
the wall of which is thinned and nearly ready to burst. For- 
tunately, unless the pus is unusually virulent, no serious harm 




Fig. 311. — Intestines Held Back by Gauze. Patient in Trendelenburg Posture. 



results. However, we should always exercise care, in such 
cases, to wall off the general peritoneum and intestine with 
several layers of gauze pads, to prevent their being soiled. 
(Fig. 311.) Occasionally, in severe cases, when the patient 
is much depressed, the persistence required for the separation 
of extensive adhesions would so prolong the operation as to 
endanger the life of the patient. It may be necessary then to 
content ourselves with mere emptying and draining of the 
suppurating cavity. The greater the experience of the operator, 
however, the less frequent will be the incomplete operation. 



IXFLAMMATIOXS. 409 

Separation of adhesions between different parts of the intestinal 
canal other than the rectum should be made as much as possible 
under the eye, and any injuries to these structures should be 
immediately repaired. The inexperienced operator should be 
careful not to mistake a thickened and adherent intestine for 
an inflamed Fallopian tube. This mistake may be avoided by 
following the tube toward the uterus before an effort is made 
toward its separation. 

During the performance of these operations the general 
peritoneum should be carefully protected by drawing back the 
intestines and omentum, and retaining them with gauze or gauze 
sponges, so that they shall not be soiled by rupture of an abscess 
cavity. After the completion of the operation, and when the 
parts have been dried, it is well to douche the cavity plentifully 
with hot normal salt solution, cleansing the surface by irrigation 
rather than by the use of the sponge or its substitutes. Drain- 
age must be decided by the indications of the individual case. 
The larger the experience of the operator, unless he is par- 
ticularly prejudiced, the less frequently will he be likely to use 
drainage. Even in the most virulent cases, with extensive ad- 
hesions, irrigation of the cavity with a large quantity of normal 
salt solution, repeating it before the cavity is closed and leaving 
a considerable quantity of fluid within the abdomen, dilutes 
any poison that may remain and renders it less active and less 
likely to produce deleterious effects. In this way drainage 
may be avoided. In suppurative peritonitis McCosh suggests 
intra -intestinal injections of saline cathartic. He cleanses the 
peritoneal cavity thoroughly with irrigation instead of sponging. 
Through a hollow needle, between one and two ounces of a 
saturated solution of magnesium sulphate is introduced into 
the small intestine at a point as high as possible in the jejunum 
or ileum. The needle-puncture is closed by a Lembert suture. 
The action of the saline produces free watery discharges, and 
thus makes the intestine act as a drainage-tube for the peri- 
toneal cavity. When drainage is used in suppurative cases, 
the gauze or wick drain, in which a number of strands are in- 
troduced into different parts of the abdominal cavity, is the 
preferable method of drainage. If the ends are carried well 
around the side of the body, and are surrounded by cotton and 
gauze at a point below the level of the internal ends, we then 
secure a siphon-like action, which more eft'ectually drains the 
cavity. 

Postural drainage, recently suggested by Clark, utilizes the 
healthy and unirritated portion of the peritoneum for absorption. 
He recognized that, in the ordinary positions of the body, 
fluids, serum, and blood are Hkely to accumulate on that portion 



410 GYNECOLOGY. 

of the peritoneum which has been injured and less able to take 
care of them, and in which there are, possibly, still remaining 
tissues impregnated with pathogenic germs. A culture-fluid 
is thus brought in contact with the germs at the most favor- 
able temperature. Such a misfortune is avoided by elevating 
the foot of the bed thirty-six inches. The patient is occasion- 
ally turned, from side to side, so that no fluid accumulates in 
the pelvis, but is drained upward upon the healthy perito- 
neum, which is abundantly able to take care of it. This pos- 
ture also, by decreasing the amount of blood that is sent to the 
injured part, saves the patient from very much of the distress 
which ordinarily results from the operation. Another advantage 
of this procedure is that it permits us to close the wound, to 
avoid the annoyance of a weakened abdomen, and thus to 
decrease the risk of hernia. In closure of the wound we must 
endeavor to utilize such measures that will bring together and 
hold in apposition the tissues, so that firm union may be secured 
and the risk of hernia lessened. Various methods of procedure 



Fig. 312. — Three-pronged Vulsellum. 

have been employed to accomplish the purpose : the introduction 
of a double row of sutures or of a series of sutures, one in the 
peritoneum, another in the aponeurosis, and another in the skin. 
The difliculty in the introduction of rows of sutures, however, 
is that not infrequently there are left dead spaces, in which 
an accumulation of fluid occurs. This later becomes infected 
and results in the formation of an abscess, which necessarily 
weakens the wall. I endeavored to obviate this difliculty by 
the employment of the figure-of-8 suture. The suture was 
made to cross just in front of the aponeurosis or that portion of 
the abdominal wall which it is most important should be main- 
tained in apposition. The flgure-of-8 suture was designed to 
accomplish the same purpose as a double row of sutures, but 
affording the advantage that the suture could be removed. It 
was found to have the disadvantage, however, that in order to 
secure apposition of the tissues, the suture was likely to be drawn 
so flrmly as to result in a slough, which produced a stitch abscess. 
I have experienced the greatest satisfaction by a com- 



INFLAMMATIONS. 



411 



bination of continuous chromic catgut suture with interrupted 
silkworm-gut sutures. Beginning at either angle of the wound, 
the catgut suture is introduced external to the aponeurosis upon 
one side of the wound, brought out in the peritoneum and fascia 
of the opposite side, and then through the edges of the peritoneal 
wound until the other angle of the wound has been reached, 
when it is brought out above the aponeurosis. The silkworm- 




gut sutures are now introduced, including all the tissues above 
the peritoneum, the wound is cleansed, and the catgut suture 
continued, uniting the edges of the aponeurosis, when the 
wound is carefully dried before the introduction of the last 
turn and the tying of the knot. Again dr3ang the wound, the 
silkworm-gut sutures are tied. This procedure gives secure 
union of the peritoneum, aponeurosis, and skin with but one 



412 



GYNECOLOGY. 



buried knot. When twenty-day catgut is used, the wound 
should be firmly secured against subsequent weakness. 

The silkworm-gut sutures serve as supports to the wound, 
and should be tied only closely enough to hold the surfaces 
in apposition. The after-treatment is similar to that of other 
abdominal operations. (Section 143.) 

Vaginal Section and Uterine Castration.— M^nj clinical 
observers have appreciated that the infected uterus, from 




Fig. 3T4. — Incision through Vagina with Thermocautery in Vaginal Excision 

of the Uterus. 



which the disease had been transmitted to the peritoneum 
and appendages, has continued to be a cause for discomfort 
and ill health after the secondary foci of infection — the ap- 
pendages — have been removed. 

Pean, in 1886, to insure relief in such cases, advocated 
the removal of the uterus through the vagina as a routine pro- 
cedure in all cases in which that organ had been involved in 



INFLAMMATIONS. 



413 



an infectious process. This operation he designated as uterine 
castration. The procedure was subsequently popularized by 
the advocacy of Segond and Jacobs. The diseased appendages 
may or may not accompany the uterus in its removal. In 
preparing for this operation the following instruments should 
be sterilized: Three double tenacula; four vaginal retractors; 
a knife; one pair of straight scissors and one pair curved on 
the fiat; four large and twelve small pressure forceps; an 




Fig. 315. — Clamp Forceps for Securing the Broad Ligament. 

angiotribe; Deschamps ligature-carrier; needle-holder; needles, 
threaded with silk loops; chromic catgut, sizes o and 2. The 
operator may also have at hand the thermocautery and a large 
number of sterile gauze sponges. The steps of the operation 
are similar to those in the performance of the ordinary opera- 
tion of vaginal hysterectomy. The patient is prepared as directed 
in Section 119. She is placed in the lithotomy position, and 
the uterus is exposed by the vaginal retractors, one anterior, 
a second posterior, and one on each side. These retractors 



v^ 




Fig. 316. — Deschamps Needle Ligature Carrier. 



are held by two assistants. The cervix is seized by a vul- 
sellum or double tenaculum, dragged down, and a circular 
incision made through the vaginal walls, which will be nearer 
the OS externum anteriorly than posteriorly. Behind the 
incision extends for half an inch or more above the os, and, 
if required, additional room can be secured in the vagina by 
lateral incisions in the vaginal wall which extend for half an 
inch outward from the circular incision, and parallel with the 
broad ligament. The incision about the uterus is often made 



414 



GYNECOLOGY. 



with the thermocautery, which has the advantage that, in 
addition to decreased bleeding, the burn prevents the surfaces 
from immediate union and affords better opportunity for drain- 
age. After cutting through the vagina the tissues are pushed 
away from the cervix with the finger, the separation between 
the bladder and the cervix is accomplished by blunt dissection 
with the finger or some blunt instrument, or by successive 
snips of the scissors. The late Joseph Eastman inserted the 
scissors, closed, near to the cervix and then separated the blades, 



"%^ 



^ 






-Drawins: Down the Fundus. 



which facilitated the dissection. The dissection can be more 
rapidly accomplished posteriorly, as there is but little danger 
of injuring the rectum. The dissection is completed front 
and back by opening the peritoneal cavity when the uterus 
is held by the broad hgaments, through which pass the uterine 
and ovarian arteries. The tissues upon each side are divided 
with successive snips • of the scissors, and the uterine artery 
is seized with forceps as soon as exposed, or immediately when 



INFLAMMATIONS. 



415 



cut. The fundus of the uterus can then be tilted forward 
through the anterior fornix of the vagina. This permits the 
cervix to be carried upward. With the fingers passed over 
the fundus of the uterus the ovary and tube are followed upon 
the tense surface of the broad ligament and dragged down, 
Avhen a pair of clamp forceps can be placed upon the broad 
Hgament to secure it. This is usually done first upon the left 
side, after which the 
broad liament is cut 
between the uterus 
and the forceps. 
This permits the 
more read}^ access 
to the right tube 
and ovary, as 
the fundus of the 
uterus is turned out 
of the way. This 
tube and ovary are 
brought down in 
a similar manner, 
the broad ligament 
clamped external to 
them, and the mass 
cut away. We have 
now the bleeding 
vessels secured by 
the pressure for- 
ceps. If the condi- 
tion of the patient 
is such as to make 
an expeditious op 
eration desirable, it 
may be completed 
by simpl}^ packing 
the vagina with 
gauze between these 
forceps, carrying the 
gauze well over the 
ends of the forceps in order that the intestine shall not impinge 
against them and become injured. The forceps and vulva 
are covered with a sterile dressing and the patient put to bed. 
The forceps should be allowed to remain for forty-eight hours, 
the gauze for four or five days. The clamp method, while 
expeditious, has the disadvantage, however, that the tissue 
enclosed in the grasp of the forceps undergoes necrosis and 




Fi.< 



iS. — Application of tlie Clamp Forceps to the 
Lower Portion of the Broad Lieament. 



416 



GYNECOLOGY. 



causes a disagreeable odor for two or three weeks subsequent 
to the operation. This condition is a worry to the patient, 
nurse, and physician. There is ahvays a possibility of the 
infection of the structures and of the peritoneal cavity, so that 
the majority of operators prefer to employ the ligature. The 
upper part of the broad ligament, that in the grasp of the upper 
clamp, may be crushed with the angiotribe and ligated with 
chromic catgut in the groove. The angiotribe, however, should 
not be employed if the tissue has undergone inflammation 






Fig. 319. — Ligation of the Broad Ligament in Vaginal Hysterectomy. 



and contains more or less exudate. The angiotribe crushes 
this tissue, indeed, almost bites it off, and, therefore, does not 
preclude the possibility of bleeding. Care must be employed 
in the use of the ligature to make sure that it is firmly tied 
and that it does not sHp. The uterine arteries, if they are 
in the grasp of the small forceps, may be ligated with catgut. 
These, if they have been picked up separately, do not require 
a large mass within the ligature. In the employment of liga- 



INFLAMMATIONS. 



417 



tures in the pelvis, the catgut should be preferred, although 
it has the disadvantage of being more likely to slip. The liga- 
ture here is very likely to become infected, consequently, if 
it is a silk hgature, it leads to a profuse discharge, to the for- 
mation of extensive granulations, and to a condition which is 
uncomfortable to the patient and a source of worry to the 
physician. Therefore, the chromic catgut should be employed 
in preference to the silk, which is almost certain to become 
infected. The ideal 
method of operating 
is that in which the 
electrothermic angio- 
tribe is employed, as 
devised by Dr. A. J. 
Downes. This cooks 
the tissues to such a 
degree that hemor- 
rhage is effectually 
controlled, and hence 
no ligature remains 
to act as a source of 
irritation. When the 
inflammatory exu- 
date in the pelvis 
has been extensive, 
and has gone on to 
suppuration, so that 
we have pus sacs in 
the broad ligament 
or in Douglas' 
pouch, the preferable 
plan of procedure is 
that the incision 
should be made 
through the poste- 
rior culdesac, the pus 
sacs opened, evacu- 
ated and irrigated 
before the general 

peritoneal cavity has been opened and disturbed. Gauze may be 
packed into the pelvis temporarily during the remaining steps 
of the operation. In some cases the uterus is so bound down 
by inflammatory exudate that the dissection through the ante- 
rior fornix of the vagina is somewhat difficult. In these cases 
the operation may be expedited by splitting through the an- 
terior lip of the uterus, holding each side of the organ with 

27 




Fig. 320. 



-Upper Portion of the Broad Ligament 
Secured by Clamp Forceps. 



418 GYNECOLOGY. 

the double tenaculum, and drawing it down while the cervix 
is being split. This affords a better opportunity to observe 
the relation of the bladder and the uterus, and to keep within 
the layer of connective tissue in the septum. Splitting the 
cervix and making traction upon its sides enable us to see the 
relation of the bladder and, consequently, to avoid injuring 
it. Another modification is the amputation of the cervix 
after the lower part of the broad ligament has been cut through. 
This permits the more ready rotation downward of the fundus 
through the anterior fornix, as it has a shorter arc through 
which to rotate. The fundus of the uterus may be rotated 
through the posterior fornix, but the anterior is preferable, 




■ «7 !^l 

Fig. 321. — The Introduction of Gauze after Removal of the Uterus. 

for the reason that it puts the broad ligament more readily 
upon the stretch and enables us the better to find the lines of 
cleavage between the tube and ovary and the other adherent 
viscera. If the ovary and tube are not readily brought down, 
or if the patient is suffering from chronic hyperplasia of the 
tubal and ovarian structures, by which these organs are often 
largely obliterated, we may apply the clamp on either side of 
the uterus prior to its removal. After the removal of the 
uterus we can then proceed in our effort to remove the ap- 
pendages upon each side; but should we fail in this or if the 
adhesions are very firm, these structures may be permitted 
to remain, taking care, of course, that all pus pockets have 



INFLAMMATIONS. 



419 



been thoroughly broken tip and packed with iodoform gauze. 
The great majority of these cases have been infected. It is 
certainly preferable to treat the wound open by packing it 
with iodoform gauze rather than to close the vagina and peri- 
toneal surfaces. Landau advocates and practises the bifur- 
cation of the uterus through the antero-posterior line as a pre- 
liminary. One half of the organ is pushed upward, the other 
is drawn down. This procedure affords much more room for 



1^^^ 


J m\^ 


JV J^ j^t%^ ' 


^"""^^^ 




j 
i 



Fis:. 



-Closure of the Vas^inal AVotmd bv Sutures. 



the manipulation necessary in the application of forceps, the 
use of the ligature, or in crushing with the angiotribe. It 
affords better opportunity, also, for dealing with the infected 
tube and ovary. As a preliminary, the peritoneum can be 
protected by packing with sterile gauze before we proceed to 
enucleate or separate the ovary and tube. In the employment 
of pieces of gauze it is very important, however, that the end 



420 GYNECOLOGY. 

of the gauze should be fixed with a pair of hemostatic forceps, 
as the gauze is very readily worked upward into the peritoneal 
cavity by intestinal peristalsis, and, therefore, it may get be- 
yond the reach of the surgeon. Nothing is more annoying 
than to expeditiously perform an operation and then have to 




Fig. 323. — -Landau's Method of Delivering the Uterus after Its Complete Median 

Section. 

lose valuable time in hunting sponges. The nurse who dis- 
penses the sponges should do nothing else, and should keep 
an accurate account of the number of sponges she has given 
out. These should be accounted for before the operation is 
considered completed. 



DEVIATIONS OF THE PELVIC ORGANS. 



421 



DEVIATIONS OF THE PELVIC ORGANS. 

407. Changed Relations of Structures of Vulva. — The re- 
lations of the structures of the vulva are modified and dis- 
torted by hypertrophy, by varicose veins, by inflammatory 
exudates and deposits, by edema, and by hernia and tumors, 
but they are, however, so intimately connected with the deeper 
structures that they are not subject to anything like displace- 
ment. All the other pelvic structures are capable of more 
or less marked displacement, still all are so closely related to 
and dependent upon uterine deviations that we will proceed 




Fig. 324. — Uterus Displaced by Distended Bladder. 



to the consideration of the uterus and its displacement as a 
primary subject. 

408. Physiologic Movements of the Uterus and the Forces 
by Which It Is Sustained. — The uterus is a freely movable 
organ. It is suspended in the pelvis, with its fundus at or a 
little above the level of the brim of the pelvis, by the action 
of the uterosacral, the uterovesical, and the inferior portion 
of the broad ligaments, and occupies the axis of the pelvis, 
with its cervix directed toward the last sacral vertebra. The 
supports of the uterus are not ligaments in the ordinary sense, 



422 



GYNECOLOGY 



but consist of connective tissue, into and through which run 
prolongations from the uterine muscular structure, so that 
the organ is virtually sustained by muscular action. That 
the uterus is supported by muscular action is evident from 
the fact that the organ moves upward and downward with 
every respiratory excursion, changes its position with that of 
the body, and is influenced by the distention and condition 
of the surrounding viscera. In the normal position, the uterus 
rests forward upon the bladder, in a position of slight ante- 
flexion, while the cervix is directed almost at a right angle 
to the axis of the vagina. Such a position is markedly changed 




Fig. 325. — Uterus Displaced by Impacted Rectum. 

by the distention of the bladder, which raises the fundus and 
decreases the angle between the uterus and the vagina until 
it becomes exceedingly obtuse (Fig. '3 24), and in marked dis- 
tention, indeed, the uterine axis becomes nearly parallel with 
that of the vagina. The cervix is pushed forward by disten- 
tion of the rectum. (Fig. 325.) When the rectum and the 
bladder are both distended, the organ is elevated, and no longer 
finds room between these two viscera. It will be seen that 
the muscles, arranged as just mentioned, support the cervix. 
The movements of the body of the organ are influenced by 
the broad ligaments on each side, which prevent it from un- 



DEVIATIONS OF THE PELVIC ORGANS. 



423 



dergoing lateral change of position, and by the round ligaments, 
which act as stays to prevent it falling backw^ard, or to draw 
it forward, when the bladder is emptied. The round ligaments 
are, of course, an insignificant force, but it must be remem- 
bered that the uterus weighs less than an ounce, and we can 
understand, therefore, how they serve to maintain the uterus 
far enough forward to permit the intra-abdominal pressure 
to be directed against its posterior surface. So long as the 
intra-abdominal pressure continues upon the posterior surface 
of the uterus, it is held forward against the bladder. It is 
also important for the maintenance of the uterus in its normal 




Fig. 326. — Scheme of Dislocated Uteri. — {Dudley.) 



place that the muscular structure of the pelvic floor shall re- 
main in normal condition. Relaxation of the vaginal walls 
and of the muscular structure, occasioned by injury to the 
pelvic floor in which the perineal muscles are torn through, — 
and, particularly, the levator ani, — withdraws a support, which 
sooner or later favors displacement. The normal condition 
of the peritoneum is a factor. This structure is certain to be 
affected by loss of muscular tone and of muscular support. It 
is not one factor, then, but several, which combine to maintain 
the uterus in its normal relations. 



424 



GYNECOLOGY. 



409. Pathologic Changes and What Constitute Them. — 

From what has been said of the physiologic changes of position 
in the situation of the uterus it can readily be perceived how 
difficult it is to draw the line of demarcation between physi- 
ologic and pathologic changes. It may be said that when the 
uterus undergoes such changes in its structure or in its envelopes 
that it becomes stable in a position which is at times regarded 
as physiologic, it becomes pathologic and is known as displace- 
ment. Thus, the uterus may be pushed forward by a distended 
bladder, which will increase the angle between its axis and that 
of the latter ; but if it does not follow the bladder forward when 
that organ is emptied, the position becomes abnormal. 




Fig. 327. — Uterus Pushed up by Tumor in Douglas' Pouch. 



These changes may result from: 

1. Neglect of hygiene on the part of an individual, either 
in permitting the bladder to become habitually overdistended 
or the rectum to be loaded with fecal matter until the uterus 
is so driven back that the intra-abdominal pressure is no longer 
directed upon its posterior, but falls upon its fundus or an- 
terior surface, which will lead to changes productive of an 
abnormal fixation. 

2. Inflammatory changes in the uterus, leading to increased 
weight of the organ, straightening of the body, loss of its normal 
curvature, and, by the weight, displacement of the organ for- 
ward, by which pressure is exerted against the fundus of the 
bladder; or, again, the increased weight produced by infiam- 



DEVIATIONS OF THE PELVIC ORGANS. 



425 



matory conditions causes relaxation of the pelvic ligaments 
and consequent displacen^ient of the uterus downward and 
backward, while the body is bent upon the cervix. This bend- 
ing may take place either forward, backward, or laterally. 

3. The presence of inflammatory material in the cellular 
tissue and in the structures surrounding the uterus causes 
its displacement by the volume of exudation, and subsequent 
displacement in the opposite direction takes place by the re- 
sulting inflammatory contraction. The uterus may be dis- 
placed as a whole, while its axis still remains parallel to what 
it was before, causing a change of location; or, again, it may 




Fig. 328. — Uterovaginal Prolapse. 

be turned upon its axis forward, backward, or laterally; may 
be bent upon its own axis; may be depressed downward; and 
may undergo torsion. 

4. The presence of growths, either of uterine or external 



410. Classification of Displacements. — As may readily be in- 
ferred from what has been stated in the previous section, the 
uterus is capable of displacement upward, downward, back- 
ward, forward, and laterally, and of being twisted upon its 
axis. Upward displacement is known as ascent; downward, 



426 



GYNECOLOGY. 



as descensus or prolapsus uteri. (Fig. 326.) The location 
of the uterus is subject to change :. thus, when it is situated 
toward the back part of the pelvis, hugging closely the hollow 
of the sacrum, it is known as a retrolocation ; close to the sym- 
physis pubis, as an antelocation ; and toward one or the other 
side of the pelvis, as a dextro- or sinistro-location, according to 
the side on which it is situated. When the direction of the axis 
of the organ is changed, it is known as a version; with the fundus 
well forward, it is an ante version; the fundus turned back- 
ward, a retroversion; and toward either one or the other side, 




Fig. 329. — Vagino-uterine Prolapsus. 



a dextro- or sinistro-version. The organ may be bent upon 
its axis, in which event the cervix and fundus approach each 
other. This bending may take place forward, backward, or 
laterally, giving rise to the terms anteflexion, retroflexion, 
and dextro- and sinistro-flexion. Finally, it may be twisted 
upon itself, producing a torsion. 

411. Ascent is the least frequent form of displacemicnt. 
Those conditions which increase the weight of the organ, natu- 
rally by force of gravity, depress it. It is only when the organ 
has attained a size so great that it is no longer accommodated 



DEVIATIONS OF THE PELVIC ORGANS. 



427 



within the pelvis that ascent occurs. This is recognized as a 
physiologic ascent in pregnancy, and occurs after the fourth 
month, when the uterus becomes so large that it can no longer 
be retained within the pelvis, and rests upon the brim. A 
similar state develops when fibroid growths are situated in 
the organ and become large. (Fig. 327.) The uterus is drawn 
or pushed up by growths which may have developed in the 
pelvis and become adherent to it. As they increase in size and 
rise out of the pelvis, they drag or push the uterus up with 
them. Ovarian tumors, extra -uterine pre^ancy, extensive pel- 




Fig. 330. — Vagino-titerine Prolapsus with Hypertrophic Elongation of the 

Cervix. 



vie exudation, hematocele, and retro-uterine growths may bring 
about an elevation of the uterus. 

412. Diagnosis. — The elevation of the uterus is readily de- 
termined by digital examination. The cervix is absent from 
its usual position in the vagina; frequently so elevated as to 
be with difficulty reached behind or even above the symphy- 
sis; often a growth or mass fills the pelvis, over which the 
cervix can not be reached. Greater difficulty is sometimes 
experienced in determining the condition which has caused 
the displacement, and this is more important than the treat- 



428 



GYNECOLOGY. 



rnent, for the latter is entirely dependent upon the cause pro- 
ducing the displacement. 

413. Descent, or Prolapsus. — -Descent or prolapsus of the 
uterus varies in degree. By this term is understood a down- 
ward displacement of the organ, which is generally associated 
with retroversion, so that retroversion is often considered 
as the first degree of prolapsus. The uterus is situated at a 
lower level, with the os directed in the axis of the vagina. The 
second degree of prolapsus is when a portion of the organ pro- 
trudes through the vulvar orifice, and the third degree when 
the entire uterus is outside of the vulva. This term includes 

a partial or complete 
prolapsus or inversion 
of the vagina. Pro- 
lapsus is also divided 
into complete and in- 
complete, according 
to the situation of 
the uterus. When the 
organ is still situated 
within the vagina or 
only a portion pro- 
trudes from the vulva, 
it is known as incom- 
plete prolapsus, but 
when the entire 
uterus is external to 
the vulva, it is called 
a complete prolapsus. 
The term procidentia 
is also applied to 
prolapsus, but only 
when the entire 
uterus is external. 
Prolapsus is further 
divided into three 
varieties, according to the relation of the uterus to the vagina. 
Thus, it is called uterovaginal prolapsus (Fig. 328) when 
the prolapsus begins in the uterus, which is extruded through 
the vagina with only partial inversion of the latter; (2) vagino- 
uterine prolapsus when the prolapsus begins in the vaginal walls 
and more or less extensive protrusion of the vagina precedes 
the prolapse of the uterus (Figs. 329 and 332). In such cases 
the prolapsus of the uterus may be incomplete, while the vagina 
is inverted, and a hypertrophic elongation of the cervix exists 
(Figs. 330 and 331). The third variety is pseudo-prolapsus. 




Fig-33r. 



-Uterus Detached, Showing Hypertrophic 
Elongation of the Cervix. 



DEVIATIONS OF THE PELVIC ORGANS, 



429 



In this condition a large portion of the cervix projects into or 
through the vulva, while the fundus retains its normal position 
and the vaginal walls are unaffected (Figs. 333 and 334). In 
the latter case the hypertrophic elongation takes place in the 
vaginal portion of the cervix. 

414. Etiology. — The causes of prolapsus may be classified 
under three heads: first, decreased support; second, increased 
weight; third, increased intra-abdominal pressure. These con- 
ditions can exert their influence separately, but they usually act 
in conjunction. Decreased support is characteristic of individ- 
uals who have given birth 
to one or more children, 
and in whom the pelvic 
structures have been in- 
jured during the process 
of parturition. Lacera- 
tion of the perineum or 
removal of the support 
of the posterior segment 
of the pelvic floor per- 
mits a protrusion of the 
anterior wall of the 
vagina and the bladder 
during the distention of 
the latter organ. This 
protrusion of the ante- 
rior segment of the pelvic 
floor, because of the close 
attachment of the blad- 
der to the cervix, drags 
upon the latter, and, 
unless the uterus is fixed 
by firm ligaments or 
inflammatory adhesions, 
the entire organ is gradu- 
ally brought into the 
axis of the vagina, with 

its fundus thrown backward, and the intra-abdominal pres- 
sure will subsequently be directed upon it or its anterior 
surface. The decreased support to the posterior wall of the 
vagina permits protrusion of this segment with the rectum, and 
the cervix is drawn upon by both the anterior and posterior 
vaginal walls. Decreased support may exist in women who have 
not given birth to children, where, owing to want of normal 
muscular development, to ill health or to too straight a sacrum, 
the support is lessened, and the muscles of the pelvic floor are 




Fi< 



?>2,2. 



-Vulvar Appearance 
uterine Prolapsus. 



of Vagino- 



430 



GYNECOLOGY. 



greatly relaxed. If, in such cases, intra-abdominal pressure is 
increased, extensive displacement results. Prolapsus may thus 
be produced in the unmarried. In marked relaxation and want 
of pelvic support, which has resulted from lesions of parturition, 
the tendency to prolapse is increased by enlargement of the 
uterus or by failure to complete the process of involution. The 
uterus remains heavy, so that these two forces, decreased support 
and increased weight, acting in conjunction, lead to descent. It 
is true, we may have prolapsus when the uterus is small; thus, 
in cases in which, subsequent to the climacteric, the patient loses 




Fig. 333- — Pseudoprolapsus. Cervix within the Vagina. 



flesh, the absorption of the fatty cushion decreases the amount 
of support, and, with enfeebled muscular action, permits a small 
uterus to be driven through the pelvis. This is a cause of pro- 
lapsus in the aged. Increased intra-abdominal pressure may 
arise from want of hygiene in clothing, where tight corsets and 
heavy skirts fastened about the waist afford insufficient room in 
the abdomen for the viscera, which are driven downward into 
the pelvis. Neglect of the evacuation of the bowels and of the 
.bladder increases the tendency to displacements. Prolapsus is 



DEVIATIONS OF THE PELAGIC ORGANS. 



431 



favored by straining at stool, by lifting and carrying heavy 
weights. Not infrequently a patient will give a history of having 
lifted a weight, or of violent straining, after which a protrusion 
was noticed at the vulvar orifice. In such cases the condition has 
existed for some time, and in the majority has been aggravated 
only at the time of the extra effort. The presence of gro^i:hs 
within the abdominal cavity — fibroid tumors, ovarian cysts — 
which press upon the uterus may force it down. In relaxation 
of the pelvic floor it is not unusual to observe a prolapsus of the 
uterus, which has been produced by the increased intra-abdominal 
pressure incident to the presence of a new gro\A^h. 




Fig. 334. — Pseudoprolapsus. Cervix Protruding from Vulva. 



415. Symptoms. — In the early stages of prolapsus of the 
uterus there are no symptoms characteristic of the condition. 
The patient complains of a sensation of weight, pressure, dis- 
comfort in the bladder, a feeling of burning in the rectum and 
dragging sensation while walking or standing — all of which may 
be associated with other conditions. As the prolapsus pro- 
gresses, the patient will notice a protrusion from the vulvar 
orifice, which is increased by straining and lifting. As this pro- 
trusion increases, the close association of the bladder with the 
cervical wall causes the uterus to be dragged down. The bladder 



432 



GYNECOLOGY. 



with exceedingly rare exceptions accompanies the displacement. 
Occasionally, however, the peritoneal fold may be driven down 
between the bladder and the uterus, and a prolapsus thus occur 
without the bladder being associated with it. With the continu- 
ation of the prolapse the anterior wall becomes more and more 
everted and, not infrequently, forms a considerable-sized tumor, 
which projects anteriorly, is increased by straining, and forms a 
tumor with a smooth, globular surface. This protrusion of the 

anterior wall of the vagina 
and bladder is known as a 
cystocele. (Fig. 335.) The 
posterior wall of the vagina 
may be likewise protruded, 
though less frequently than 
the anterior. In cases of 
inversion of the vagina the 
posterior wall is generally 
associated, although even 
then not to the same degree 
as the anterior (Fig. 335). 
The posterior protrusion is 
known as a rectocele. The 
uterus is separated from 
the rectum by a prolon- 
gation of the peritoneum 
which extends below the 
rectum on the posterior 
wall of the vagina. In the 
inversion of the posterior 
wall of the vagina to form 
a rectocele, the intestine 
may or may not be associ- 
ated with it. Occasionally, 
the want of support of the 
anterior rectal wall permits 
it to be pushed downward, 
and form a diverticulum 
considerably below the 
anus, which renders the evacuation of the bowel difficult, and 
at times impossible, unless it is pushed up with the hand, when 
the scybalous masses situated in the pouch can be extruded. 
In complete prolapsus of the vagina with the formation of 
an extensive cystocele a portion of the bladder is situated 
below the level of the internal orifice of the urethra, and as 
this protrusion extends, the bladder is incompletely evacuated, 
the retained urine with mucus in this reservoir undergoes 




F^g- 335- — Anterior and Posterior Colpocele. 



DEVIATIONS OF THE PELVIC ORGANS. 



433 



decomposition, forming an ammoniacal urine, which irritates 
the mucous membrane of the bladder and produces a cystitis. 
In this diverticulum, with a plug of mucus as a nucleus, a 
calculus of considerable size can form; indeed, one weighing 
an ounce has been found in such a sulcus. With the protru- 
sion the distress of the patient is greatly increased, because of 




Fig- 536. — Cystocele. 



the bladder irritation and the friction of the protruding tumor 
against the clothing and limbs of the patient. The urethra, 
instead of passing upward and backward as in the normal 
situation, passes backward, and even downward. The pro- 
truded vagina in a complete prolapsus may form a large tumor 
extending half way to the knees, in which tumor is situated a 
28 



434 



GYNECOLOGY. 



portion of the bladder, the uterus, ovaries, tubes, and prolapsed 
intestines — an extensive hernia (Fig. 338). The mucous mem- 
brane of the vagina loses its moistened, reddish appearance, 
and instead becomes pale, thickened, and covered with flakes of 
epithelium, and resembles the appearance of the skin. Bathed 
with urine and fecal matter, irritated by the clothing and by 
friction against the limbs, and congested from the decubitus, 
ulceration is produced upon the external os and upon the sides 




Fig. Zd)"!- — Prolapsus with Both Rectocele and Cystocele. 



of the tumor, which, at times, causes extensive ulceration and 
adds greatly to the discomfort of the patient. In the early stage 
of the displacement the menses are increased, possibly irregular, 
and occur at shorter intervals. Leukorrheal discharge is present, 
often profuse, as a result of the congestion of the organ. As the 
prolapsus becomes still more extensive, and approaches nearer 
to complete prolapsus, menstruation is likely to be decreased and 
.the leukorrheal discharge disappears. The displacement does 



DEVIATIONS OF THE PELVIC ORGANS. 



435 



not necessarily interfere with conception, as pregnancy has often 
occurred with complete prolapsus; but in the later stages the 
patient is more likely to be sterile. 

416. Diagnosis. — The patient considers every protrusion 
from the vulva to be a prolapsus or falling of the womb. The 
diagnosis would seem self-evident, but it must be conceded 
that not every such protrusion is necessarily a prolapse of the 
uterus, and it is important to determine the degree, the form 
of prolapsus, and the structures involved. This knowl- 
edge is obtained by inspection, while the patient is directed 
to increase the displacement by straining and bearing down, 
and is further confirmed by touch. A protrusion from the 




-Irreducible Prolapsus Tin Tumor Contained Uterus and a Large 
Pyosalpinx. Ulceration of Cervix. 



anterior part of the vulva which, on separating the labia, is 
found to be continuous with the urethra and anterior wall, is a 
cystocele. It is the most frequent protrusion from the vulva, 
and may be accompanied in part or wholly by the uterus. 
Cystocele is recognized by the finger entering the vagina be- 
hind the protruding mass, which can generally be replaced 
with ease. The cervix, when accompanying it, will be situated 
at its posterior surface. A protrusion of the posterior wall 
of the vagina is recognized by its continuity with the peri- 
neum, and the finger enters the vagina in front of it. Con- 
siderable protrusion of the vaginal walls occurs without much, 
if any, displacement of the uterus. The degree of displace- 



436 



GYNECOLOGY. 



ment of the anterior and posterior walls of the vagina is recog- 
nized by the introduction of the finger around the uterus. Thus, 
the cervix can protrude from the vulva without there being 
any shortening of the posterior, and but slight shortening of 
the anterior, wall of the vagina. With inversion, or com- 
plete prolapse of the vagina (Fig. 337), the summit of the pro- 
trusion is occupied by the cervix, which can appear as the 

normal-sized opening, or 
external os; or, when 
laceration of the cervix 
has occurred, the lips 
may be widely everted,' 
and show an irritated 
cervical mucous mem- 
brane. When prolapsus 
is complete, the uterus is 
situated in the tumor, 
external to the vulva, 
generally in the position 
of retroversion or retro- 
flexion ; rarely it is ante- 
flexed. The uterovaginal 
form of prolapsus is de- 
termined from the vagino- 
uterine variety by the 
lessened involvement or 
association of the vagina 
with the protrusion. In 
the uterovaginal form 
(Fig. 339) the uterus 
is driven through the 
vagina, drags with it 
the upper part, and 
finally results in partial 
inversion of the canal. 
When the prolapsus is 
complete, the uterus is 
likely to be small and 
its cavity short. In the vagino-uterine variety the prolapse 
begins at the lower segment of the vagina by a rolling outward 
of the anterior and posterior walls. The thickened and everted 
vaginal walls drag upon the cervix, and lead to displacement 
of the uterus; or, where the fundus is fixed by the condition 
of its ligaments or by inflammatory disorders, the cervix is 
drawn out, and causes a very marked elongation of the uterus. 
This condition is determined by placing the fingers of one hand 




Fig- 339- 



•Prolapsus without Protrusion of 
Vaginal Walls. 



DEVIATIONS OF THE PELVIC ORGANS. 



437 



in front of, and those of the other hand behind, the protruding 
mass, when we determine the situation of the fundus of the 
uterus. (Fig. 340.) The protruding tumor can be grasped 
between the thumb and fingers of one hand, when the fingers 
will -distinguish the uterus outside the vulva, or the cord-like 
cervix protruding into the vagina, when hypertrophic elon- 
gation of the cervix exists (Fig. 341). The situation of the 
fundus can still further be recognized by the introduction of 
the finger into the rectum. By dragging upon the cervix with 
a tenaculum while passing the finger into the rectum the at- 




Fig. 340. — Determination of the Position of the Uterus by Bimanual Palpation. 



tenuation of the neck is determined, and the situation of the 
fundus is recognized (Fig. 342). In pseudoprolapsus the fundus 
is but little displaced from its normal situation. There is a 
protruding mass from the vulvar orifice, and the introduction 
of the finger into the vagina show^s that the vaginal walls are 
not displaced; this elongation has taken place in that portion 
of the cervix which is situated below the vaginal attachments. 
It generally results from enlargement and increased weight 
of the cervix. The anterior segment of the vagina is attached 
to the cervix at a lower level than the posterior. Occasionally, 



438 GYNECOLOGY. 

we find a protrusion of the anterior wall of the vagina, and 
at its posterior surface the cervix, while the introduction of 
the finger into the vagina shows that the posterior vaginal 
wall is not displaced (Fig. 343). In other words, the elongation 
has occurred in that portion of the cervix situated between 
the attachment of the anterior and the posterior walls. 

In considering the differential diagnosis we must concede 
the possibility of the protrusion having arisen from a cyst 
in the anterior wall of the vagina, a hernial protrusion through 
the posterior fornix, a fibroid polypus, and an inversion of the 
uterus, associated with inversion of the vagina. Cyst of the 




Fig. 341. — Recognition of Uterus with Thumb and Fingers of One Hand. 

vagina is recognized by bimanual palpation. A catheter or 
sound is introduced into the bladder, and a finger into the 
vagina, by which the abnormal thickness of the anterior wall 
is readily recognized and the character of the condition disclosed. 
The bimanual examination can reveal a fibroid polypus pro- 
truding from the orifice of the cervix by a more or less distinct 
pedicle. Traction upon the tumor and the introduction of a 
finger into the rectum will disclose the position above of the uterus. 
Displacement of the rectum is not generally associated with pro- 
lapsus of the vaginal walls, and, when so, is less intimately 
connected. Inversion of the uterus is recognized by a pro- 



DEVIATIONS OF THE PELVIC ORGANS. 439 

truding tumor, which does not present an external os, is more 
sensitive, tinder careful examination shows the orifices of the 
Fallopian tubes, and is a globular, well-shaped tumor, which 
.can, still further, lead to an inversion of the vagina in which 
the relation of the cervix to the tumor and the vagina is readily 
determined. 

Enterocele, or hernia through the posterior fornix of the 
vagina, is a rare condition, although I have seen two such cases 
in which the hernia extended to the vulva (Fig. 344). The 



'<< ' 




/ 



Fig. 342. — Diagnosis of Position of the Utenne Body by Rectal Touch. 

tumor is generally more elastic and is greatly distended. The 
absence of the uterus, in association with it, is recognized. 
On reduction of the hernia the opening into the posterior fornix, 
through which it had passed, is readily recognized. 

417. Prognosis. — The results of treatment must generally 
depend upon the stage of development, the existing compli- 
cations, and the manner of life the patient is required to live. 
The earlier the displacement comes under observation, the 
less radical will be the means required to maintain the organ 
in its replaced position. When both uterus and vagina are 



440 



GYNECOLOGY. 



prolapsed, changes have taken place which are beyond our 
skill to restore to the previous condition. While much can be 
done for the comfort of the patient in all cases, still in some, 
however, it may be necessary to sacrifice the uterus and part 
of the vagina. The irritation to which the vagina is subjected 
will sometimes lead to the development of an epithelioma 
(Fig. 345). Not infrequently we will find gravity sores and 
extensive ulcerations as a result of friction and the interference 
with the circulation. The restoration and maintenance of 
the pelvic organs in their proper place will depend upon the 




Fig. 343. — Hypertrophic Elongation of the Cervix. Anterior Vagina Everted, 
while Posterior Retains Its Normal Position. 



complications which may be associated with the displacements. 
The most frequent complication is the sequel of inflammatory 
changes, in which the displaced organs are more or less fixed 
by extensive exudation and adhesions. In procidentia the 
protruding sac or hernia, in addition to the uterus and part 
of the bladder, is likely to contain the ovaries and tubes, and 
even a large portion of the large and small intestines. In- 
flammatory changes in such a condition may lead to an ir- 
reducible hernia, which must necessarily add very much to 
the distress and discomfort of the patient. Such a patient 
can neither sit nor stand with comfort. In one patient (see 



DEVIATIONS OF THE PELVIC ORGANS. 



441 



Fig. 338) a large protruding sac contained the uterus, ovaries, 
and tubes, the latter having become infected, and resulted 
in the formation of a quite considerable-sized abscess. For- 
tunately, the condition was irreducible, for otherwise the re- 
duction of such a mass into the abdominal cavity might readily 
have resulted in rupture of the tube and general infection of 
the peritoneum. In one instance I was obliged to remove 
the uterus because of a partial necrosis of its structure. Or- 
dinarily, hysterectomy would not be the operation of election, 
as the removal of the uterus leaves an open space, which it is 
difficult to thoroughly close, and favors the subsequent develop- 
ment of a vaginal hernia, which is difficult to remedy. AVith 




Fig. 344. — Enterocele through the Posterior Vaginal Fornix, 

the retention of the uterus and its proper anchorage in the 
pelvis, it serves as a plug and obstruction to the re-development 
of a hernia. It is self-evident that the patient who is enabled 
to live a luxurious life need not be subjected to the same treat- 
ment as the woman who must maintain herself, and, possibly, 
the members of her family, by laborious industry. The former 
by rest and proper hygiene may be able to prevent the develop- 
ment of the prolapsus, consequently an operative procedure 
may be delayed or mechanical means employed to overcome 
the condition, while the woman who must earn her lii^ng at the 
washtub or by continuous maintenance of the upright position 
will be required to subject herself to operative interference in 
order to prevent a more extensive displacement. 



442 



GYNECOLOGY, 



418. Treatment. — The treatment of prolapsus uteri must 
necessarily depend upon the extent of the displacement, the 
involvement of the vagina, the distention of the vaginal orifice, 
and the age and physical condition of the patient. The most 
important treatment is prophylaxis. This consists in the care- 
ful management of the wonian during labor and the puerperium ; 
the early repair of lacerations of the cervix and perineum; 
the examination of the patient subsequent to her delivery 
to determine the condition and situation of the uterus. The 
advent of inflammatory conditions should be followed by care- 
ful rest and judicious treatment ; the employment of hot vaginal 
douches; cold applications over the abdomen; rest in bed; 
depletion of the uterus; and, where endometritis exists, the use 
of the curet. A heavy uterus should be sustained by tampons 




Fig. 345. — Vagino-uterine Prolapse Complicated by Proliferating Epithelioma. 



or a pessary, until the process of involution has been com- 
pleted. The treatment of prolapsus may be divided into hy- 
gienic, mechanical, and operative. Hygienic treatment com- 
prises the wearing of proper clothing. A woman with a ten- 
dency to prolapsus of the uterus should not wear tight clothing. 
The increase of the intra-abdominal pressure necessarily ag- 
gravates the displacement; consequently, the clothing should 
be loose. Skirts should be suspended from the shoulders rather 
than about the waist; the bowels should be kept regular and 
all straining at stool avoided ; lifting and carrying heavy weights 
should not be undertaken ; the patient should frequently assume 
the knee-chest position, and while in this attitude, separate 
the vulva in order that the air may enter and magnify the in- 
fluence of gravity in restoring the displaced organs. This 
position should be particularly assumed for several minutes 



DEVIATIONS OF THE PELVIC ORGANS. 443 

as a last act before retiring, and patients should assume the 
lateral or prone position rather than the recumbent. 

Mechanical treatment of prolapsus consists : (i) in the reduc- 
tion of the displaced uterus or its return to a normal position ; (2) 
in the employment of means to insure that this position will be 
maintained. The first step, then, in treatment is to replace the 
displaced organs. Ordinarily this is not difficult, as the increased 
size of the vaginal canal readily permits the organ to be carried 
upward to its proper place. Where the displacement, however, 
is complicated by inflammation with extensive exudation into 
the pelvis, it may result in matting together the uterus, ovaries, 
and tubes with knuckles of intestine and portions of omentum. 
Such a condition will render the restoration of the organs ex- 
ceedingly difficult, if not impossible, without resort to operative 
interference. Sometimes the displaced uterus, from passive 
congestion or edema, will become so large and engorged that 
it can not be replaced through the pelvic canal. This is par- 
ticularly prone to occur in those cases in which the prolapse 
is complete and the uterus and vagina have been subjected 
to friction against the clothing, causing the formation of gravity 
sores, and swelling to such an extent that the mass is rendered 
too large to be returned through the pelvis. Such a tumor 
may sometimes be reduced in size by the application of an 
elastic bandage, or by keeping the patient perfectly quiet in 
bed, with the pelvis somewhat elevated, and cold applications 
applied to the swollen structures. Cloths wet with lead-w^ater 
and laudanum and covered with oiled silk, over which an ice- 
bag is applied, will frequently be effective in relieving the en- 
gorgement, and after a few days' treatment will result in such 
a decrease in size as to permit the parts to be reduced. The 
organ can be replaced with much greater ease by placing the 
patient in the genupectoral position. While the patient is 
in this position, the tumor can be drawn down, compressed 
with the fingers, and gradually pushed up to its normal site 
within the pelvis. A mass too large to permit of its replace- 
ment with the patient in the dorsal position can generally 
be returned while in the knee-chest posture. When the uterus 
is fixed by inflammatory exudate, the patient should be put 
to bed, the parts subjected to pelvic massage, and in the in- 
tervals the uterus supported as high as possible by tampons 
of cotton and gauze, or, probably still better, lamb's wool 
saturated with medicinal agents, in which glycerin shall form 
an essential part. This treatment should be alternated with 
hot vaginal douches. Inflammatory adhesions may also be 
overcome by the employment of continuous weight or pressure. 
This is rather difficult to apply within the pelvis, because of 



444 



GYNECOLOGY. 



its being the most dependent portion of the trunk. The patient 
can be placed upon her side, with the pelvis somewhat elevated. 
Pressure is then obtained by introducing a small rubber bag, 
containing mercury, into the vagina. The continued pres- 
sure thus directed upon the surface will promote the absorp- 
tion of the exudation, and, by change of position, the uterus 
can be gradually worked free from the exudate. Thus, tampons, 





Fig. 346. — Ring Pessary, 



Fig. 347. — Disc Pessary. 



douches, massage, and pressure should be employed until 
the uterus becomes freely movable and its reposition accom- 
plished. This, of course, is desirable as a preliminary to the 
employment of such a mechanical support as the pessary. 
In cases of prolapsus the pessary acts by so distending the 
upper part of the vagina that the levator ani and the muscles 
of the pelvic floor form a support for the instrument, and thus 
prevent the displacement. Consequently, it is necessary that 





Fig. 348. — Smith-Hodge Pessary. 



Fig. 349. — Munde Pessary. 



the pessary shall be of sufficient size to accomplish this dis- 
tention. The pessaries most frequently employed are the 
ring (Fig. 346), the bulb, the disc (Fig. 347), the Smith-Hodge 
(Fig. 348), or Thomas or Munde (Fig. 349) modification of 
the latter. Numerous other pessaries are employed, such 
as the soft -rubber pessaries (Fig. 350), the Zwank or bat-like 
pessary (Fig. 351), the Gehrung (Fig. 352), the double curved 
pessary, the saddle or Graily Hewitt (Fig. 353), according 



DEVIATIONS OF THE PELVIC ORGANS. 



445 



to the purposes designed to be accomplished by their designers. 
In the employment of many of these pessaries, however, it is 
absolutely necessary that the pelvic floor shall afford a point 
of resistance to the intra-abdominal pressure. In cases in 
which the pelvic floor has been lost, or where the prolapsus 
is of the vagino-uterine variety, the pessary, having no point 
of resistance, is at once extruded when the patient makes a 





Fig. 



350. — Hoffman Soft-rubber 
Pessary. 



Fig. 351. — Zwank Pessary. 



straining effort, or even upon standing. In such cases a pessary 
may be employed with an external support. This is in the 
form of a cup with a stem attached to straps which are fastened 
to a belt around the waist. Such an instrument, however, 
is exceedingly uncomfortable; the stem and straps are irritating 
to the delicate external surfaces. The cup may cause ulceration 
and abrasion of the cervix and vagina. The employment 





Fig. 352. — Gehrtmg Pessary. 



Fie. 



35> 



-Hewitt Cradle Pessarv 



of a pessary in prolapsus can only be palliative ; it has no power 
of restoring the function of the part. However, a patient 
came under my observation who had worn a pessary for twenty- 
six years. This had produced such marked abrasion and 
irritation of the vagina that granulations had sprung up which 
enveloped the greater part of the instrument with new tissue. 
The pessary was cut with bone pliers, and each half removed 



446 GYNECOLOGY. 

separately, leaving undisturbed the mass of cicatricial tissue 
by which the uterus was subsequently supported. I have 
seen, in several instances, the bulb or glass-ball pessary worn 
for a long period of time, until it resulted in cicatricial changes 
in the vagina, which formed the support for the atrophied uterus. 
The maintenance of the uterus by the establishment of cicatricial 
tissue has been attempted by the injection of quinin and other 
irritating materials into the broad ligaments. This was done 
in order to establish a cellular inflammation, which should 
cause such contraction of the connective tissue as to retain 
the uterus in position. Such a plan of treatment, however, 
is attended with too much danger to justify its employment. 
The operative treatment is the only procedure which can 
be considered radical, or affording hope for the restoration 
of the structures and their maintenance in normal position. 
In the employment of such measures I wish to direct your 
attention to the three causes which have been assigned for 
the development of prolapsus. These are, increased weight 
of the uterus, decreased pelvic support, and increased intra- 
abdominal pressure. The malposed uterus is rendered heavy 
by a condition of subinvolution or chronic inflammation, which 
has in part resulted from obstruction to its circulation. Not 
infrequently will we find that the cervix has undergone hyper- 
trophic elongation, and that the vaginal walls are dragging 
upon this elongated portion of the organ. The first step, then, 
in the restorative process, should be the amputation of the 
cervix. This decreases the size of the uterus, not only by the 
amount of the cervix removed, but by the favorable metabolism 
thus engendered. The amputation may be free or the double- 
fiap or single-flap method can be employed (see Amputation 
of Cervix, p. 218), according to the particular pathologic con- 
dition present. In performing this operation, we would suggest 
that the cervix be sutured with chromic catgut, as such sutures 
can be allowed to remain ; moreover, the stretching of the newly 
united surfaces, consequent upon the removal of sutures of 
other denomination, is avoided. The second indication is 
met by narrowing the vaginal canal and reconstructing the pelvic 
floor. Early in the history of gynecology various operations 
were devised to secure this object. Sims did a triangular 
denudation upon the anterior wall, the surfaces of which were 
united and the canal thus reconstructed. The method of 
freshening the surface will largely depend upon the character 
and form of the prolapsus. The protrusion of the anterior 
wall of the vagina, for which these procedures are considered, 
is known as cystocele. Furthermore, the maintenance of the 
uterus in position* by narrowing the vagina will be especially 



DEVIATIONS OF THE PELVIC ORGANS. 



447 



applicable to the correction of the cystocele. In cystocele we 
have to deal not only with the protrusion of the vaginal wall, 
but also with an accompanying prolapse of the bladder; a por- 
tion of the bladder is consequently oftentimes below the level 
of the internal orifice of the urethra. The portion thus dis- 
placed, as we have seen, affords an opportunity for ammoniacal 
fermentation and decomposition of the urine. In the sulcus 
or depression thus formed, not infrequently calculi are devel- 




Fig. 354. — Anterior Colporrhaphy. Anterior Vaginal Wall Removed. 



Oped, which further aggravate and add to the distress of the 
patient. Any operative procedure, then, should comprise 
not only the contraction of the anterior vaginal wall, but the 
elevation of the bladder to a higher level. This change of 
the bladder position is accomplished by an incision through 
the anterior vaginal wall into the connective tissue between 
the vaginal and vesical surfaces. The edges of this incision 
are'held with forceps, while, by blunt dissection or with sue- 



448 



GYNECOLOGY. 



cessive snips of the scissors, the vesical surface is dissected off; 
this dissection is extended upon either side to a degree sufficient 
to permit the removal of the relaxed tissue of the anterior 
vaginal wall. The bladder should then be pushed away from 
the cervix, up to or even through the peritoneum (Fig. 354). 
This dissection is followed by tucking the bladder up from 
below, and stitching it fast to the cervix at a higher level. This 
method renders the posterior surface of the bladder more tense. 

Some operators have 
advocated anchor- 
ing the bladder to 
the anterior parietes 
through an abdomi- 
nal incision, but such 
a procedure will be 
necessary in but few 
cases. The traction 
upon the bladder and 
its fixation to the 
anterior surface of the 
uterus will decrease 
the pressure against 
the reconstructed va- 
ginal walls. The va- 
ginal incision should 
be united from near 
the cervix, and the 
suturing extend out- 
ward, the cervix be- 
ing pushed as we pro- 
ceed. In this manner 
a strong anterior seg- 
ment of the pelvic 
floor is established 
(Fig. 355)- The su- 
turing should be done 
in a vertical line with 
a continuous chromic 
catgut suture, which should be locked at every second turn, 
in order to prevent puckering of the wound. The aim of 
the operator should be to make a long anterior wall, to hold 
the cervix backward, and, consequently, tilt the fundus uteri 
forward. In greatly relaxed vaginal walls the excision may 
be made circular, and the wound closed with the Stolz suture 
(Fig. 356). This, however, contracts the vagina in every 
direction and, therefore, is less favorable in the majority of 




Fig- 355- — Wound Closed. 



i 



DEVIATIONS OF THE PELVIC ORGANS. 



449 



cases than the method of anterior colporrhaphy, already de- 
scribed. The ordinary method of performing the operation, 
known as anterior colporrhaphy, consists in making a denuda- 
tion which does not penetrate the entire vaginal wall. When 
sutured, such a denudation forms a wall of connective tissue, 
which is not so durable as the method we have described. The 
operation upon the anterior vaginal wall should be supplemented 
by one upon the posterior. This may be slight or extensive. 




Fig. 356. — Stoltz's Purse-string Suture. 

according to the amount of relaxation. The restoration'^of, 
the posterior segment may be accomplished by performing 
the operation known as the modified Garrigues-Hegar, or the 
operation designed by Emmet. For a description of the method 
of performing these operations see page 256. The decrease 
in the size of the uterus, the restoration of the pelvic floor, 
as described, will, in some cases, prove effective in maintain- 
ing the uterus in its proper position. In others, however, 

29 



450 GYNECOLOGY. 

in which the uterus is large and does not maintain its proper 
axis, but drops backward, the intra-abdominal pressure will 
tend to drive it through the newly united canal and reestablish 
the hernia. It is consequently important that the uterus 
should be anchored within the abdomen, to prevent such an 
occurrence. This anchoring of the uterus may be accomplished 
by the operation known as ventrosuspension, or, still better, 
ventrofixation. For the description of this operation and 
its indications and contraindications see page 491. The same 
purpose can be effected by one of the operative procedures 
which utilize the round ligaments, as, the Alexander, the Gil- 
liam-Ferguson, the Ries, or other modifications, which will 
be described later. The aim, of course, of the operative pro- 
cedure is to maintain the fundus of the uterus forward. This 
can be accomplished by vagino-uterine fixation, or by shortening 
the round ligaments through the vagina. These operations 
can readily be done in association with those upon the anterior 
wall of the vagina, as in the procedure we have already described. 
When the bladder is pushed away from the cervix, it is very 
easy to enter the peritoneal cavity through an anterior colpotomy 
and employ the opportunity thus afforded to break up adhesions, 
to treat ovarian and tubal disease, and to restore the uterus 
to its normal position. The incision through the posterior 
vaginal fornix is also employed for shortening the uterosacral 
ligaments. It will readily be understood that if the cervix 
is carried upward and backward, the fundus will necessarily 
fall forward. The contraction of the uterosacral ligaments, 
or the tissue in which they are usually situated, is of special 
value in marked prolapsus, for if the ventrosuspension or fixa- 
tion, or one of the operations upon the round ligaments alone 
is done, we would have the uterus hanging and dragging upon 
its anchorage. Shortening the uterosacral ligaments, however, 
lifts up the cervix and, consequently, throws forward the fundus, 
thus making the uterus serve as a plug to obstruct the egress 
through the pelvis. Freund advised in aged women, in whom 
the prolapsus was marked, and the condition of the patient un- 
favorable for a radical operation, that silver wire sutures should 
be passed so as to form successive rings beneath the uterus. 
The introduction of the sutures should begin immediately 
beneath the cervix, so as to push up and maintain the organ 
at a higher level. He directed that they be drawn moderately 
tight and fixed by twisting, the ends are then cut off and pushed 
into the vesicovaginal septum. The silver wire thus secured 
forms successive bands or hoops around the restored vagina, 
which it was thought would maintain the uterus in place. My 
own experience, however, is that upon very slight exertion 



DEVIATIONS OF THE PELVIC ORGANS. 



451 



the entire condition is reestablished. Moreover, the silver wire 
sutures are likely to cause irritation and possibly the formation 
of abscess, which will ultimately require their removal. In 
prolapsus of large uteri, complicated by inflammation of the 
tubes and ovaries, with bands of adhesion fixing omentum 
or coils of intestine to the uterus and bladder and with the 
subsequent cicatricial 
changes, the preferable 
plan of procedure, in 
my judgment, is the 
partial or complete re- 
moval of the organ. 
Even so radical a pro- 
cedure should be sup- 
plemented by a plastic 
operation upon the va- 
gina, in order to nar- 
row the canal and af- 
ford better support to 
the abdominal viscera. 
Such patients, even 
though old, bear opera- 
tion fairly well. Where 
the condition of the 
uterus will permit of 
its retention, the organ 
then should not be 
sacrificed. We have 
already cited reasons 
why hysterectomy 
should not be the oper- 
ation of election. In 
hypertrophic elonga- 
tion of the cervix it 
may be difficult, by 
simple amputation of 
the cervix and fixation 
of the uterus, to suffi- 
ciently elongate the va- 
gina to prevent recur- 
rence of the hernia. In such cases, especially where the woman 
has passed the climacteric, the supravaginal amputation of the 
fundus uteri, through an abdominal incision, followed by suturing 
the stump, covered with peritoneum, to the broad ligaments 
upon each side, as advocated by Baldy, will be effective, or, 
when the vagina is very much relaxed, we may sew the stump 




Fio-. 



357.— First Stage of Dudley's Bilateral 
Denudation of the Vaginal Walls for Pro- 
lapsus. 



452 



GYNECOLOGY. 



of the cervix directly to the abdominal parietes, as advocated 
by Noble. E. C. Dudley asserts that the part of the vagina 
most resistant to displacement is its lateral surface, and that, 
instead of narrowing the vagina on the anterior and posterior 
walls, the preferable plan of procedure would be to denude an 
elliptical surface upon either lateral fornix, with the long diam- 
eter antero-posterior. The edges of newly made surfaces are 
apposed and secured with sutures through the long diameter. 
From this a lateral denudation is made upon either side, in 
which the sutures are introduced from behind forward and from 

above downward, in 
such a way as to lift 
up the anterior wall 
of the vagina (Figs. 
357 and 358). Even 
in marked cases of 
prolapsus, sutures 
may be introduced so 
as to in some degree 
serve to anchor the 
lateral surfaces of the 




rVag- 



vagina. 

419. Urethrocele. 

— The urethra, in ex- 
tensive cystocele, is 
generally, more or less 
involved. As has al- 
ready been recog- 
nized, the intimate 
connection of the 
bladder and urethra 
with the anterior va- 
ginal wall necessitated 
their association in 
any prolapsus of the 
latter structure. When a segment of the bladder is situated 
below the internal orifice of the urethra, the upper part of the 
urethra, as a consequence, becomes prolapsed. The lower seg- 
ment of the urethra, however, generally retains its normal 
situation. Occasionally, we may have a protrusion from the 
central portion of the urethra, which forms a sac-like projec- 
tion (Fig. 359), at the lower portion of the anterior wall of 
the vagina. This latter condition is independent of any uterine 
or vaginal displacement. This projection, on the introduc- 
tion of a catheter, is found to be a part of the urethra. It is 
at times so large as to form a kind of diverticulum, over which 



Fig. 358. — Dudley's Operation, showing Denuda 
tion upon One Side of the Vagina. 



DEVIATIONS OF THP: PELVIC ORGANS. 



453 



the urine flows, without entering it, or enters it only to a limited 
extent. Pressure over the urethrocele causes a discharge of 
quite profuse purulent material, although pus has not previously- 
been found in the urine. The treatment consists in dissecting 
out the sac, a catheter having been previously introduced as a 
guide. The opening in the urethra is closed while the catheter 
is in place. The vaginal wall is then sutured over this wound, 
and the urine is subsequently evacuated through a permanent 
catheter for two or three days. 

420. Dislocation of the uterus is a displacement in which 
there is but slight change in its axis. These dislocations may 
be forward, backward, or lateral. The organ is more or less 
fixed in the abnormal position by inflammatory changes, fre- 
quently in the form 
of inflammation of the 
cellular tissue. In ante- 
position the uterus is 
situated close to the 
symphysis, generally 
above it, and the con- 
dition is produced by 
growths or by accu- 
mulations in the pelvis 
which push up the 
uterus. The organ once 
fixed in the abnormal 
position, remains. In 
retroposition the uterus 
is situated at a lower 
level, and close to the 
hollow of the sacrum. 
It results from inflam- 
matory changes which contract, and fix the organ; thus, a hem- 
atocele in its earlier stages may push the uterus forward into a 
state of anteposition, but later, as the collection becomes absorbed 
and organized, contractions occur which draw the organ back- 
ward. When the contraction involves the region of the folds 
of Douglas or the uterosacral ligaments, the fundus of the 
organ will be pushed forward, and an anteflexion will be es- 
tablished. It is only when the organ has previously been 
the seat of metritis and has become so rigid that it resists the 
tendency to flexion that it retains the retroposed position. 

Lateral position, either right or left, is generally due to 
inflammation in the cellular tissue of the broad ligament. In 
the acute stage of inflammation the organ may be pushed to 
the side opposite to that on which the exudation occurs. As 




Fig. 3 



59-- 



-Urethrocele. 



454 GYNECOLOGY. 

the condition becomes chronic, the inflammatory material con- 
tracts, and the uterus is drawn to the affected side. These 
displacements cause no special symptoms. The symptoms, 
when present, are due to the complications or conditions which 
have produced the displacement and are a consequence of the 
displacement. 

421. Diagnosis.— The situation of the displaced organ is 
recognized by bimanual examination. The fixed position and 
situation are usually sufficient to establish the diagnosis. In 
lateral displacement the organ is not in a median position, 
and on manipulation moves more readily toward the affected 
side. In a woman whose abdomen is very fat or the abdominal 
wall quite rigid, the posterior dislocation is often difficult to 
differentiate from retroversion. The introduction of the sound 
would afford information, but the advantage derived from 
determining the position is insufficient to compensate for the 
danger from its use. An assistant dragging upon the cervix 
with a tenaculum or vulsellum while either the vaginal or rectal 
bimanual is practised will generally afford a definite deter- 
mination as to the character of the malposition. 

422. Torsion.^ — Torsion is generally associated with either 
a retroposition or a lateral position, and is due to an irregular 
contraction of the portion of the broad ligament which has 
been subject to cellular inflammation. This contraction twists 
the uterus upon its axis, so that the cornua may be turned 
anteroposterior instead of being situated laterally. The entire 
uterus can be thus twisted, so that, upon inspection, the os, 
instead of being transverse, will present an oblique or nearly 
anteroposterior line. Torsion also results from the presence 
of growths in one or the other broad ligament or of an ovarian 
tumor to which the tube is adherent. As the tumor enlarges 
it drags upon the uterus and twists it. This lesion is frequently 
overlooked, and presents no symptoms of special importance. 
(Treatment, see page 497.) 

423. Anteversion.^In anteversion, the uterus is found 
with its fundus forward and the cervix directed backward or 
upward and backward (Fig. 360). The organ may be fixed 
in the abnormal position by complications, such as inflamma- 
tion, which may cause adhesions between the fundus and an- 
terior parietal peritoneum, or more frequently in the cellular 
tissues about the uterus, the cervix, or in the uterosacral liga- 
ments. An inflammatory process of the uterosacral ligaments 
with a normal uterus will produce flexion, but when the latter 
organ is stiffened by long-continued inflammation, it causes 
anteversion. The uterus is considerably increased in size; its 
walls are thickened and often rigid and firm. The normal 



DEVIATIONS OF THE PELVIC ORGANS. 



455 



flexion has disappeared and the canal is perfectly straight. 
This position of the uterus is caused by increase of weight, 
and in severe versions the fundus will lie forward upon the 
bladder or against the symphysis, while the cervix may be 
directed upward and backAvard. 

424. Etiology.— Any disorder w^hich increases the weight 
of the uterus increases the tendency to an antedisplacement. 
When the uterus has been the site of previous inflammation, 
particularly a metritis, this displacement is necessarily an 
anteversion. Metritis, subinvolution of the uterus, pelvic cellu- 




Fig. 360. — Anteversion of the Uterus. 



litis, occurring in the posterior portion and in the utero-sacral 
ligaments ; fibroid growths in the fundus ; ovarian growths — all 
may cause this form of displacement. 

425. Symptoms. — Anteversion presents no characteristic 
symptoms. The symptoms are those w^hich are associated with 
the complication by which it is produced. The patient may 
complain of a sensation of distress, from pressure upon the 
bladder, of frequent micturition, and of pain or a dull ache over 
the region of the symphysis. 

426. Diagnosis. — Anteversion is readily determined by bi- 
manual palpation. The cervix is situated high posteriorly.. 



456 GYNECOLOGY. 

and often reached with some difficulty, while the uterine body 
can be traced forward and is found to rest upon the bladder. 
Not infrequently the fundus lies well against the symphysis. 
The situation of the fundus in the anterior portion of the ab- 
domen, the absence of any angle in the uterus, and its size, 
weight, and more or less immobility, definitely differentiate it. 
427. Treatment." — As we have already seen, ante version is a 
symptom or sign rather than an actual disease. It is a develop- 
ment that arises as a natural consequence of increased weight of 
the uterus, and the treatment must necessarily be that which is 
applicable to the existing complication. The most common 
complication is inflammation, causing hypertrophy or hyper- 
plasia of the uterus, an irritative infiltration and proliferation 
of the tissue element. The inflammatory condition may exist 
with or without adhesions. The treatment of the condition, 
then, in the great majority of cases, is that of existing inflam- 
mation — hot vaginal douches, tampons medicated with agents 
which are expected to exert an influence in decreasing the 
size of the uterus. This decrease can frequently be accom- 
plished, to a considerable degree, by thoroughly dilating the 
uterine cavity with laminaria tents, and after their removal, 
swabbing the interior of the organ with tincture of iodin, a sat- 
urated solution of iodin crystals in 95 per cent, carbolic acid, 
or a saturated solution of iodoform in ether. Following such 
an application, the decrease in size of the uterus may still further 
be promoted by packing the organ with iodoform gauze and by 
placing a tampon of iodoform gauze beneath it. This raises 
the organ to a higher level and promotes its circulation. Fur- 
thermore, the uterus can be dilated with graduated bougies, 
its cavity cureted, and applications made as suggested. Where 
the uterus is free from adhesions, it may be supported by a 
pessary. The pessaries which were devised for the purpose 
of elevating the fundus have not proved satisfactory. The 
retroversion pessary in some cases of heavy uteri is particularly 
serviceable, although it may seem a paradoxical instrument 
to employ in ante version, but it does, however, afford relief 
by holding the uterus at a higher level. Operations upon the 
cervix, amputation, or the repair of a laceration of the cervix 
will establish a process of metabolism which will decrease the 
size of the uterus. AVhen the uterosacral ligaments have not 
become shortened through inflammatory processes and thus 
caused an irremediable displacement, the operation devised by 
Sims may be practised. This consists in making a transverse 
denudation upon the anterior lip, another upon the vaginal 
wall at a suitable distance from it, and uniting these two sur- 
faces by sutures (see Fig. 361). As a result of this operation. 



DEVIATIONS OF THE PELVIC ORGANS. 



457 



the cervix is drawn toward the vulvar outlet, the fundus is 
tilted upward, and a more correct position is secured. When 
the uterus is fixed by 
adhesions, in addition to 
the treatment already sug- 
gested, pelvic massage will 
prove beneficial. Two fin- 
gers in the vagina are 
hooked behind the cervix 
and press the fundus of 
the organ upward; while 
the external hand is ro- 
tated over the fundus, the 
fingers pressing down along 
its sides and in front of 
it, push the fundus back- 
ward. While the fundus 
is pushed backward w4th 
the fingers of the external 
hand and drawn forward 
with the fingers in the 
vagina, bands of adhesion 
are put upon the stretch 
and are manipulated to 
such an extent that their 
absorption is promoted. 
The manipulation of the 
uterus promotes absorp- 
tion of inflammatory ex- 
udate within its walls, and 
thus assists in decreasing 
its size, so that by the 

time the adhesions are stretched and loosened, the uterus is so 
reduced in size that the patient is much relieved. In some 

cases, where a boring pain 
is experienced over the 
symphysis, the wearing of 
a cincture or belt (Fig. 362) 
will support the abdomi- 
nal viscera and relieve the 
intra-abdominal pressure to 
such a degree that the ache 
or discomfort will disap- 

Fig. 362.— Abdominal Belt. pear. 

428. Retroversion. — In 

retroversion the uterus is turned with the fundus backward. 




Fig. 361. — Sims' Operation for Anteversion. 




458 



GYNECOLOGY. 



(Fig. 363.) The cervix is directed forward against the pos- 
terior wall of the bladder. This displacement varies in degree 
according to the relations of the cervix and uterus to the 
axis of the vagina. The maximum degree is a backward dis- 
placement in which the fundus lies low in the hollow of the 
sacrum, with the cervix directed upward. Retroversion is recog- 
nized as an early stage of prolapsus. With this displacement 
the intra-abdominal pressure is directed upon the fundus or upon 
the anterior wall of the uterus, which favors downward displace - 




Fig. 363. — Retroversion. 



ment, so that we usually find retroversion associated with a 
certain amount of descent of the uterus. 

429. Etiology. — The most frequent cause of retroversion 
is a lesion of pregnancy. Retroversion occurs in the unmarried 
or sterile woman, but much less frequently. It is produced 
by decreased support of the ligaments, particularly of the 
uterosacral, which permits the uterus to sag downward and 
to be rotated backward; the latter action is occasioned by a 
distended bladder, until finally the ligaments lose their mus- 
cular tone and the organ does not regain its normal position. 
Retroversion can be produced by traumatism, as when the 
person falls from a height and strikes upon the feet or, par- 



DEVIATIONS OF THE PELVIC ORGANS. 459 

ticularly, upon the buttocks, and by the presence of growths 
in the uterus or in the ovaries. 

430. Symptoms. — Retroversion causes few symptoms. The 
discomfort in the majority of cases arises from compHcations. 
Patients may have marked retroversion without experiencing 
any inconvenience or being aware of the condition until it is 
brought to their knowledge. Inflammatory complications pro- 
duce a sensation of weight or dragging, as if everything were 
about to protrude when the patient stands or walks. The 
menstrual flow is increased, producing menorrhagia; occasion- 
ally, there is an irregular, bloody discharge, or the intermen- 
strual intervals are shortened, or, as a result of the coexisting 
catarrh, the patient will have a profuse leukorrhea. The pro- 
jection backward of the fundus and pressure of the cervix 
against the bladder cause a more or less frequent desire to 
urinate. Not infrequently there is an extension of the inflam- 
mation to the vesical mucous membrane, which produces cystitis. 
Pressure of the uterus upon the rectum increases the tendency 
to constipation, interferes with the rectal circulation, and 
develops hemorrhoids and flssure of the anus. An injury 
of the anus or rectum under these circumstances is slow to re- 
cover, which makes it important, in cases of rectal disease, 
to ascertain the condition of the uterus before we resort to 
any operative interference. 

431. Diagnosis. — Digital examination discloses the cervix 
uteri in the axis of the vagina, or looking forward and sometimes 
upward. Through the posterior vaginal fornix, the examining 
finger recognizes a mass which is continuous on a straight line 
with the cervix. The bimanual examination discloses the 
absence of the fundus from the anterior fornix. The rectal 
bimanual affords an opportunity to explore the fundus and 
even the anterior surface of the uterus. (For treatment, see 
Retroflexion, Section 442.) 

432. Lateral Version. — Lateral version is a form of dis- 
placement in which the fundus is situated to one side of the 
pelvis, while the cervix is directed toward the other. This 
condition is produced by cellulitis in the broad ligament, and 
by intraligamentary growths, either fibroid or ovarian; in 
marked cases of inflammation contraction can occur in the 
base of one broad ligament, and in its upper part on the op- 
posite side. This produces a fixation of the uterus directly 
transverse to the pelvis, not unusually with a certain amount 
of torsion. The lateral version causes no special symptoms, 
and is readily recognized by a bimanual palpation. 

433. Anteflexion. — In anteflexion the uterus is bent upon 
its axis, with the fundus forward, while the cervix lies more 



460 



GYNECOLOGY. 



or less in the axis of the vagina. The flexion may be sHght 
(Fig. 364) — but Httle more than normal; indeed, any flexion 
which is fixed is an abnormal one, even though it may not be 
greater than the ordinary bending of the uterus. From a slight 
flexion we may have a very acute one (Fig. 365), in which the 
fundus and cervix seem to lie upon each other at a very acute 
angle. The anterior wall of the uterus, at the point of flexion, 
undergoes a change in which there is a substitution of flbrous 
tissue for the muscle -wall. The posterior surface becomes 
exceedingly thinned where it bends over the anterior. (Fig. 




Fig. 364. — Slight Degree of Anteflexion. 

368.) The anteflexion ma}^ be mobile or immobile. The former 
results from a heavy fundus when the cervix is in a more or less 
fixed position. Raising the fundus, we can tilt it backward, and 
leave the uterus in a position of retrofiexion, so that at times 
the organ is anteflexed; at others, retrofiexed. Not infre- 
quently a diagnosis of antefiexion will be made, and at a 
subsequent examination by another person the uterus is found 
retrofiexed. If the fact that the organ is mobile is not re- 
membered, an error in diagnosis will be attributed to the first 
investigator. In the immobile uterus the fiexion is fixed. Ante- 



DEVIATIONS OF THE PELVIC ORGANS. 



461 



flexion, again, may be regarded as physiologic, pathologic, 
and indifferent. A physiologic anteflexion is one which corre- 
sponds to the normal condition of the uterus; a pathologic, 
one in which the flexion is more or less fixed or is greater than 
normal; while in an indifferent anteflexion the bending causes 
no symptoms. 

434. Etiology.— Anteflexion is probably next to the most 
frequent form of uterine displacement, and it occurs less fre- 
quently in the married than do the retrodisplacements. It 
occurs with greater frequency in the unmarried or nulliparous 




Fig. 365. — Acute Anteflexion. 



woman, and is a result of congenital conditions, or, rather, 
those which are associated with the earlier development of 
the uterus. Anteflexion may be ascribed, first, to the long 
cervix of the puerile organ, the situation of which, in the vagina, 
necessitates the fundus bending forward over it. Second, 
inflammation in the uterosacral ligament or in the cellular 
tissue posterior to the uterus, which draws the cervix upward 
(Fig. 369), promotes, in a flexible body, its falling forward, 
and the angle between the body and the cervix is increased. 
Third, the displacement arises from localized inflammation 



462 GYNECOLOGY. 

at the site of the placenta, when situated upon the posterior 
uterine wall. Involution is more rapid in the anterior, and 
the shorter wall becomes the string of the bow which bends 
the uterus forward. Fourth, anteflexion is produced by growths 
in the fundus of the uterus. 

435. Symptoms. — The symptoms most frequently attributed 
to anteflexion are sterilty and dysmenorrhea; but when un- 
complicated by inflammation, neither of these symptoms is 
necessarily present. The patient with marked anteflexion 
generally suffers from chronic vesical distress. Pain occurs 
when the bladder is moderately distended, micturition is fre- 
quent, and generally there is a sensation of distress and annoy- 
ance, which follows the evacuation. These symptoms, how- 
ever, are not infrequently produced by inflammation in the 
bladder, so that, as a rule, the urine should always be carefully 
examined. Dysmenorrhea has been attributed to an obstruc- 
tion of the canal from which there is an accumulation of material 
within the uterine cavity, and the organ has to go into labor 
to expel it. As flexion does not cause dysmenorrhea when 
the lesion is uncomplicated by inflammation, it is evident that 
the latter is the cause of the symptom, and that the hyperemia 
prior to and coincident with menstruation produces pain during 
the distention of the inflamed surfaces rather than an obstruc- 
tion of the canal. Even in the congenital conditions the dys- 
menorrhea does not occur with the first menstruation, but 
later, when there is distinct evidence of the development of in- 
flammatory trouble. 

436. Diagnosis. — ^Anteflexion is recognized by digital and 
bimanual palpation. The cervix is situated in the axis of 
the vagina, and, by carrying the finger in front of it, a body 
is felt in the anterior fornix of the vagina, between which and 
the cervix a distinct angle is recognized. During bimanual 
palpation this angle can to some degree be straightened, and 
the relation of the flexion to the cervix and body is more 
distinctly recognized. The' flexion is particularly determined 
by passing the index-finger into the lateral fornix, first upon 
one side and then upon the other; by pressing from above 
we are able to recognize the lateral borders of the uterus and 
the absence of any growth. We can be in doubt as to whether 
the mass found in front is the fundus uteri or a fibroid growth 
attached to the anterior wall. Each condition may afford 
an equal sized angle. The method we have already described, 
of passing the finger along the lateral aspect of the uterus, 
will enable us to differentiate them. By changing the position 
of the organ, and pressing it well forward with the hand over 
the abdomen, we can outline the posterior surface of the fundus, 



DEVIATIONS OF THE PELVIC ORGANS. 463 

and determine that its size and relations correspond to those 
of the cervix to the fundus, rather than to a growth. When 
the uterus is fixed, bimanual palpation is difficult. The posi- 
tion of the organ can be determined by the introduction of a 
uterine sound into. the canal. The use of the sound, however, 
under these or any other circumstances, is fraught with so 
much danger that it is preferable to administer, if necessary, 
an anesthetic for the further practice of the bimanual, rather 
than to make an intra-uterine exploration. 

Rectal palpation with the digital finger, while the thumb 
of the same hand is placed in the vagina against the cervix, 
and the other hand over the abdomen, enables us to bring 
the uterus definitely under observation. 

437. Treatment. — Anteflexion requires treatment only when 
it is associated with symptoms, and these are usuall}^ the re- 
sult of complications. The symptoms may be caused by com- 
plications incident to changes in the structure of the uterus 
itself, as inflammation either in the wall of the organ or in the 
surrounding structures. It may be incident to the various 
constitutional conditions, as a rheumatic or gouty diathesis, 
the effect of neurasthenia, but in such cases the treatment 
may be constitutional or a combination both of constitutional 
and local measures. The most frequent symptoms associated 
with this displacement are those of dysmenorrhea or painful 
menstruation, and sterility. That these symptoms, however, 
are not necessarily the result of anteflexion alone is evident, 
from the many cases in which the patients with marked ante- 
flexion have both menstruated painlessly and given birth to 
children. Patients suft'ering from dysmenorrhea, associated 
with anteflexion, should be encouraged to live an outdoor life. 
Hygienic measures are particularly important. The clothing 
should be suitable, and the extremities be warmly clad. Very 
frequently women who suffer from dysmenorrhea while in 
our northern climates, will be absolutely free from this symptom 
when residing in the South, or in the Bermuda Islands. Meas- 
ures should be instituted to improve the general nutrition, 
to obviate the sluggish circulation, to regulate the bowels. 
Such patients are often improved by bicycle -riding, playing 
golf, and anything which leads to an outdoor life. Pelvic 
or uterine congestion should be decreased by the administration 
of iodids and bromids, the employment, particularly, a few 
days to a week before the menstrual period, of gelsemium or 
Pulsatilla, taking five drops of the fluid extract of gelsemium 
or ten drops tincture of pulsatill^, three or four times in the 
twenty-four hours, until the patient exhibits signs of its physi- 
ologic action. Th^Toid extract has proved of value in these 



464 



GYNECOLOGY. 



cases, when the drug is given in doses of three to five grains 
two or three times in the twenty-four hours. Douches, tam- 
pons, painting the vault of the vagina with tincture of iodin, 
gauze packing, and pelvic massage are all of service. The 
pessary, particularly the Graily-Hewitt (Fig. 353) or the Thomas 
anteflexion pessary (Fig. 366), which tilts up the fundus of the 





Fi-. 



366. — Thomas Anteflexion Pes- 
sary. 



Fig. 367. — Stem-pessary. 



uterus, have had their advocates. Their efficacy, however, 
is somewhat doubtful. Pelvic massage is of special value in 
these cases, as the manipulation of the uterus serves to straighten 
the organ and promote a healthy condition of its circulation. 
When the patient is not improved by douches, tampons, or 
constitutional measures, the uterus may be dilated by the in- 
troduction of a laminaria tent. This procedure should be done 

under most thorough aseptic 
precautions, with the vagina 
thoroughly cleansed, the cervi- 
cal canal rendered as aseptic 
as possible, and the tent itself 
sterilized, preferably by dry 
heat. However, the tent may 
be placed for several minutes 
in a solution of iodoform and 
ether, or in equal parts of alco- 
hol and carbolic acid, prior to its 
introduction. The cervix should 
be seized with a double tenac- 
ulum, sponged with a solution 
of formalin, and by traction 
straightened so that the tent can be the more readily intro- 
duced. As large a tent as the caliber of the cervical canal will 
allow should be employed. The tent is removed in from twelve to 
fourteen hours, after which the uterine cavity is irrigated, if neces- 
sary cureted, swabbed with a saturated solution of iodin in carbolic 
acid or of iodoform in ether. The canal may or may not be packed 




Fig. 368. — Section Showing Thinning 
of Cervical Walls at the Angle of 
Flexion. 



DEVIATIONS OF THE PELVIC ORGANS. 



465 



with iodoform gauze. The dilatation with tents may be re- 
peated at intervals until the tendency, to displacement appears 
to be overcome and the complicating involvement of the uterus 
has subsided. Inflammation in the cellular tissue about the 
uterus, or in the tubes and ovaries, as evidenced by their being 
enlarged and fixed in the pelvis, should be considered a contra- 
indication to the employment of tents. The dilatation can be 
accomplished by graduated bougies and their employment 
followed by curetment and the use of the glass drain. Twenty- 




Fig. 369. — Anteflexion Associated with Contraction of Uterosacral Ligaments. 

five years ago the employment of the stem-pessary was a favorite 
method of overcoming an anteflexion. The stem was one- 
eighth of an inch shorter than the uterine cavity; the patient 
was required to wear it for a considerable length of time (Fig. 
366). The objection to the stem-pessary is that it is a source 
of irritation, affords constant danger of infection to the uterine 
mucosa, and may lead to the development of more serious 
trouble. The favorite treatment of Sims was a bilateral in- 
cision; occasionally one through the posterior lip. Unless 
precautions are taken to prevent union, the parts are reunited. 
Even when precautions are employed, cicatricial tissue forms, 
which subsequentlv causes distress, sometimes greater even 

30 



466 



GYNECOLOGY. 



than the pre-existing condition. The posterior Hp can be 
split up to the angle of flexion and its cervical and vaginal 
lining membranes united by sutures, to prevent reunion. Oc- 
casionally, after such an operation, the cervix spreads out 
owing to the intra-abdominal pressure, and the more delicate 
cervical mucous membrane is thus exposed to pressure and 
irritation, resulting in endometritis and formation of cysts 
of Naboth, which will require continuous treatment. Splitting 




Fig. 370. — Dudley's Operation for Anteflexion, by Incising and Suturing the 

Posterior Lip. 



the anterior lip has been advocated. This is performed by 
dissecting the bladder from the anterior wall of the cervix to 
the level of or above the point of flexion. A grooved director 
is then introduced into the uterus and the cervix is incised. 
As the incision approaches the os, it is carried around to the 
side of the cervix. The cervical mucous membrane is united 
to that of the vaginal wall. This enlarges the opening from 



DEVIATIONS OF THE PELVIC ORGANS. 



467 



the front and prevents obstruction, but is subject to the same 
objection made to the posterior operation, in that it exposes 
delicate surfaces to irritation and subsequent inflammation. 
E. C. Dudley has devised an ingenious operation, in which he 
splits the posterior lip beyond the vaginal attachment; the 
surfaces are held apart by tenacula and the incision is deepened 
upon the cervical side with a knife. A wedge-shaped piece is 




371.— Completion of Dudley's Operation, by Transverse Denudation and 
Suturing of the Anterior Lip. 



removed from each side, and the sutures are so introduced 
as to unite the edge or apex of the incision on each side with 
the base. By this method, eversion of the cervical mucous 
membrane is prevented. (See Fig. 370.) The anterior lip 
of the cervix is then amputated, and the wound closed with 
transverse sutures, which push back the cervical orifice and 
straighten the canal. (See Fig. 371.) Nourse, recognizing 
that the flexion corresponded to the shorter wall, made a bi- 



468 



GYNECOLOGY. 



lateral incision to the level of or a little above the angle of 
flexion. Traction is then made upon the posterior lip, which 
results in straightening the canal. The new surfaces are apposed 




J 



m. 



Fig. 372. — Nourse's Operation Ijy Splitting the Cervix and Resuturing the 

Incisions. 




Fig- 373- — Operation Completed. 



and secured with sutures, leaving the posterior lip longer. When 
the latter is half an inch or over in length, it is amputated by 
the flap method, thus making it the same length as the anterior 



DEVIATIONS OF THE PELVIC ORGANS. 



469 



lip. The raw surfaces are united by suture (Figs. 372 and 
373). When the elongation is short, it is left to contract. 
C. A. L. Reed advocated opening the abdomen and removing 
a wedge-shaped piece from the posterior wall of the uterus 
opposite the angle of flexion. This surface is closed by vertical 
sutures and restores the organ to normal position. Burrage 
advises, in proper cases, incision of the uterosacral ligaments 
and the performance of a ventrosuspension, thus raising the 
fundus of the organ upward. 

438. Retroflexion. — In retroflexion the fundus is bent back- 




Fig. 374. — Retroflexion of Slight Degree. 



ward upon the uterine axis, and, according to its degree, lies 
toward the rectum (Fig. 374) or is forced well down into Douglas' 
pouch (Fig. 375). The cervix is in the axis of the vagina. The 
retroflexion may be mobile or immobile, may be pathologic 
or indifferent, but can never be said to be physiologic. This 
form of displacement is very frequently a sequel of version. 
The uterus becomes retroverted and the abdominal pressure 
then drives the fundus downward, bending it upon its axis, 
forcing it into Douglas' pouch (Fig. 376). 



470 



GYNECOLOGY. 



439. Etiology. — Retroflexion is produced by metritis; sub- 
involution; inflammation of the placental site, in the anterior 
wall of the organ; fibroid growths in the fundus or anterior 
uterine wall (Fig. 377), parametric inflammation, or cellulitis of 
the anterior segment of the pelvic floor, which draws the cervix 
forward; localized peritonitis; or contraction following hemato- 
cele (Fig. 378), by which the fundus of the organ is drawn back- 
ward. 

440. Symptoms. — -Retroflexion, like the other forms of dis- 
placement, when uncomplicated presents no special symptoms. 




Fig. 375. — Retroflexion of Extreme Degree. 

It produces a sensation of weight and pressure, not infre- 
quently pain in the region of the anus, an uncomfortable sen- 
sation down the posterior surface of the lower extremities, 
points of anesthesia over the thighs, congestion, partial ob- 
struction of the rectum, obstinate constipation, and not infre- 
quently a sensation that the intestine is so obstructed that the 
bowel can not be evacuated. Development of hemorrhoids, 
anal fissures, and more or less prolapse of the rectal mucous 
membrane not unusually follow. Menstruation is irregular and 
profuse, or the menstrual intervals are shortened, and leukor- 
rhea is quite profuse. 



DEVIATIONS OF THE PELVIC ORGANS. 



471 



441. Diagnosis. — Digital examination discloses the cervix 
situated at a lower level in the pelvis, occupying the axis of 
the vagina or directed a little anteriorly; the finger in the pos- 
terior fornix recognizes a body slightly above, or even below, 
the cervix, which is rounded, may be movable or fixed and 
somewhat larger than the normal fundus. Between it and the 
cervix is a distinct angle, though the structures can be traced 
from one to the other. The finger in the anterior vaginal fornix 
and the other hand over the abdomen, discloses the absence 
of the fundus uteri from its normal position. The flexion is 




Fig. 376.— Retroflexion Following Version 



apparently increased by pressure upon the cervix, and the fundus 
is driven more deeply into the culdesac. By pressing the 
finger upward on either side of the uterus and cervix the lateral 
margins can be determined. Digital examination through 
the rectum enables us to pass directly over the fundus and 
to feel to some degree its anterior surface, which now becomes 
posterior. Retroflexion of the uterus can be confounded with 
fibroid growths (Fig. 379) situated in the posterior uterine wall, 
adherent ovarian growths (Fig. 380), and pelvic inflammatory 
exudation. (Fig. 381.) The introduction of the sound into 



472 



GYNECOLOGY. 



the uterine canal, and its passage backward into the mass, 
would be definite evidence that a retroflexion exists; but, as 
in other uterine conditions, this procedure is fraught with so 
much danger that it is preferable to make the diagnosis with- 
out it, and, if necessary, even to leave it uncertain. With 




Fig 377. — Retroflexion Produced by Fibroma of Anterior Uterine Wall. 



^<rBLADDEf\. 




Fig. 378. — Retroflexion the Sequel of Inflammatory Adhesions. 



a careful bimanual examination, as has been advised, by the 
rectum, the vagina, or both, we are generally able to deter- 
mine the relations of the uterus to the surrounding parts, and 
absolutely to fix the diagnosis. AVhen the existence of pelvic 
exudate or immobility of the uterus and a resistant or thick 



DEVIATIONS OF THE PELVIC ORGANS. 



473 



abdomen prevent its accomplishment, the patient should be 
given an anesthetic. 



/ 



/ 



^"^" 




Fig. 379. — Retroflexion Simulated by Posterior Uterine Myoma. 




Fig. 3 So. — Retroflexion Simulated by Small Ovarian Cyst in Posterior Culdesac. 



442. Treatment of Retroversion and Retroflexion. — As retro- 
flexion is simply a bending of a version, we will, therefore, con- 



474 



GYNECOLOGY. 



sider the treatment of these two conditions together. As 
the majority of the other displacements are not characterized 
by symptoms, unless complications are present, so, in these 
conditions, symptoms are not manifest without the existence 
of complications. The organ, however, in maintaining a retro- 
position, interferes with its circulation, which results in con- 
gestion and subsequently in more or less inflammation. There- 
fore the treatment of the complications is ineffective so long 
as the displacement remains. The relief of the inflammatory 
condition is expedited by maintaining the uterus in a correct 
position. Treatment largely depends upon the duration of 
the displacement, the changes which the structures have under- 




Fig. 381. — Anteflexion and Retroflexion Simulated by Pelvic Exudation. 



gone, and the ability of one to replace and maintain the organ 
in proper position. No means for maintaining the uterus in 
position are effective until it has first been accurately replaced, 
after which it can be supported with relief of many of the dis- 
tressing symptoms. Three methods are generally recognized 
as proper for replacing the organ. These are: (i) The bimanual. 
The patient is placed in the dorsal position with her limbs 
flexed. Two fingers are introduced into the vagina, while the 
fingers of the other hand are placed over the abdomen (Fig. 
382). The middle or long finger is passed into the posterior 
fornix of the vagina to press up the fundus, while the index- 
finger is carried in front of the cervix to push it backward. 



DEVIATIONS OF THE PELVIC ORGANS. 



475 



The pressure against the lower end of the lever carries the 
opposite end, the fundus, forward, until it can be grasped by 
the external hand and brought into a position of ante version. 
In some cases the fundus of the uterus is caught beneath the 
promontory of the sacrum and cannot readily be dislodged. 
If the cervix, however, is grasped with a double tenaculum 
or vulsellum, and drawn down, while the fundus is pushed up 
with the finger in the vagina or rectum, the fundus uteri is 
readily displaced from beneath the promontory and the cervix 
can then be carried backward. The second procedure con- 
sists in placing the patient in the genupectoral position and 
the employment of the Sims speculum to open the vagina. 




Fig. 382. — The Retroverted Uterus Replaced; Patient in Dorsal Position. 



The atmospheric pressure balloons the vagina and the uterus is 
carried to the upper part of the canal. This procedure, how- 
ever, does not of itself correct the position, as the uterus, though 
elevated, may still be retroflexed or retroverted. The posi- 
tion, when uncomplicated, may be readily corrected by seizing 
the cervix with a tenaculum or vulsellum, and drawing it to- 
ward the vaginal orifice, and then carrying it backward and 
upward. The fundus is thus dislodged and the position corrected. 
A third procedure consists in the employment of the uterine 
sound. With the patient in the dorsal position, two fingers are 
introduced into the vagina and the sound, carried between 



476 



GYNECOLOGY. 



them, enters the os and is introduced to the fundus and then 
rotated. The external end of the sound is carried through 
a wide arc so as to do as Httle injury to the internal mucous 
membrane as possible, while the handle of the sound is de- 
pressed and the finger in the posterior fornix pushes the fundus 
upward. This combined movement carries the fundus for- 
ward until it can be controlled with the external hand. In 
spite of the most careful precautions, the uterine mucous mem- 
brane will be injured by this method of procedure. It is ex- 
ceedingly difficult to avoid the danger of the introduction of 
infectious material into the uterus, which necessarily favors 
the development of further complications. For such reasons, 
the sound should not be employed, especially as every purpose 
attained by its use can be readily accomplished by the employ- 




Fig. 383. — Schultze's Method of Replacing an Adherent Retroverted Uterus. 



ment of the dorsal manipulation or with the patient in the 
genupectoral position. Various jointed sounds have been 
devised for the purpose of replacement of retrodisplaced uteri, 
but these instruments are open to the same objections offered 
to the use of the ordinary sound. 

In adherent uteri none of these methods of procedure will 
accomplish the restoration of the displaced organ. When 
the adhesions exist between the posterior uterine surface and 
the anterior rectal wall, the intestine may be dragged up with 
the uterus and apparently permit it to assume its normal posi- 
tion; but as soon as the supporting force is removed, the uterus 
is drawn back and, if mechanical efforts are employed to main- 
tain it in position, the fundus is bent backward and the retro- 



DEVIATIONS OF THE PELVIC ORGANS. 



477 



flexion is greatly increased. If adhesions are present and they 
are not too firm and of too long duration, pelvic massage affords 
a valuable method for overcoming their baneful influence and 
promoting their absorption. The massage should be supple- 
mented by the use of tampons. In some cases the pressure 
of an air pessar}^ within the vagina stretches the bands of ad- 
hesions, promotes their absorption, and supports the uterus. 
Schultze advocated a procedure which is very eft^ective in over- 
coming recent adhesions. The patient is placed in the dorsal 
position, with the muscles well relaxed by an anesthetic. Two 
fingers are introduced into the rectum, while the thumb in the 
vagina against the cerA'ix steadies the uterus until the rectal 




Fig. 384. — Second Step in Replacing Uterus by Schultze's Operation. 



fingers, one on either side of the fundus, can invert and draw 
down the bowel and separate it from the uterine surface (Figs. 
383 and 384). As the adhesions are separated and the uterus 
is set free, the external hand grasps the fundus and draws it 
forward, after which the remaining bands of adhesion are broken 
up. Care must be exercised in carrying out this procedure 
not to employ too much force, other^A^se the intestine may 
very readily be injured. There is more danger, hoAvever, of 
injuring the tubes or ovaries, when these organs are adherent. 
An adherent tube may be torn and liberate poison at the seat 
of inflammatory trouble, which, particularly if of a purulent 
character, would be followed by a violent attack of pelvic or 



478 GYNECOLOGY. 

possibly general peritonitis. With purulent inflammation or 
pus collections in the tube excluded, the absorption and loosen- 
ing of the adhesions of the ovary, tube, and uterus can be 
effected by pelvic massage. If the adhesions are extensive and 
the vagina tender, especially when its posterior fornix is more 
or less obliterated by the long duration of the displacement, 
the uterus can be temporarily supported by the employment 
of vaginal tampons, medicated or not, as the conditions require. 
The employment of continual pressure over the abdomen or 
within the vagina may be effected by shot-bags or the employ- 
ment of rubber bags containing mercury. Three to five pounds 
or more of shot may be applied over the abdomen to make 
pressure over a mass of exudate and thus promote its absorp- 
tion and the setting free of an adherent uterus. The absorp- 
tion of the vaginal exudate may be expedited by the use of 
mercury, applied in a rubber bag. Such a weight introduced 
into the vagina, with the position of the patient changed from 

time to time in order to subject 
different portions of the exudate to 
the weight, promotes its absorption 
and the consequent loosening of the 
uterus and pelvic structures. 

When the uterus is free from 
adhesions and, consequently, can be 
readily replaced, we can at once re- 
sort to the use of a pessary. Some 
of the more prominent retrodisplace- 
Fig. 385-— Schuitze Pessary, ^ent pcssarics are the Hodge (Fig. 

348), Thomas, Munde (Fig. 349), 
and the Schuitze (Fig. 385) instruments. The various modi- 
fications of the Hodge pessary consist of a posterior bar with 
converging side bars which are united by a shorter bar an- 
teriorly. Laterally, the pessary has the shape of a letter S. 
The posterior bar is carried behind the cervix into the pos- 
terior fornix. In its modification by Thomas and Munde, the 
posterior bar is thickened, which makes a larger mass in the 
fornix. The pessary does not support the body of the uterus 
on its posterior bar, but it so drags upon the posterior vaginal 
fornix as to pull against the cervix and lift it up, until the other 
end of the lever — the fundus — is held so far forward that the 
intra-abdominal pressure is directed upon the posterior uterine 
surface. This pulley-like action of the pessary is readily seen 
in Fig. 386, which shows the proper position of the pessary 
in relation to the uterus and vagina. It has already been 
emphasized that the pessary does not support the body of the 
uterus, and that the position of the organ must be corrected 




DEVIATIONS OF THE PELVIC ORGANS. 



479 



before the introduction of the instrument. The result of an 
attempt to employ the pessary to correct the position of the 
uterus can be seen in Fig. 387. It is very important that the 
pessary should not be unduly long. When too much pressure is 
produced, laceration of the vagina occurs, rendering the pa- 
tient unable to retain it, or, if the instrument is too long, it 
may project from the vulva and cause irritation about the urethra 
or neck of the bladder, and much discomfort in sitting. The 
proper length of the pessary is readily determined by the intro- 
duction of two fingers into the vagina to measure the distance 
between the distended posterior vaginal fornix and the internal 
margin of the symphysis. The proper width of the pessary 




Fig. 386. — Proper Position of the Pessary. 



is appreciated by determining the extent to which the fingers 
can be separated without undue lateral pressure in the vagina. 
The proper size of the instrument to be employed is thus as- 
certained. AVhile a pessary too long produces the conditions 
we have already mentioned, one too short allows the fundus 
of the uterus to fall backward over its posterior bar and in- 
creases the retroflexion and adds to the distress of the patient. 
It is difficult to maintain the pessary in place where the vagina 
is much relaxed. If the uterosacral ligaments are much elon- 
gated, and the posterior fornix distensible, the pessary will 



480 



GYNECOLOGY. 



fail to maintain the uterus in its normal position, and, more- 
over, it will permit the organ to drop back and rest upon the 
instrument (Fig. 387). Schultze designed the pessary known 
as the figure-of-8, which is very effective for such cases. This 
pessary laterally is similar in shape to the Hodge instrument, 
forming a letter S. The lateral bars of this pessary are twisted 
to form a figure-of-8, the upper loop of which surrounds the 
neck of the cervix and carries it upward, while the inferior loop 
is so broad that it receives support from the vagina and does 
not incline to prolapse. Should the figure-of-8 prove un- 
satisfactory, the sledge pessary of Schultze may be efficient 




Fig. 387. — Faulty Position of the Pessary. 



(Fig. 388). Its posterior end has a bar curved forward, which 
rests in front against the cervix, and holds it back, while at 
the same time traction is made upon the cervix through the dis- 
tention of the posterior fornix by the upper part of the instru- 
ment. The pessary should be sufficiently broad to impinge 
against the side walls of the vagina to prevent it being displaced 
downward. It distends the vagina in three directions — in 
length, laterally, and in the antero-posterior direction. When 
adhesions are present, the pessary is badly borne and is harm- 
ful. It is at all times a foreign body and produces a certain 
amount of irritation in the vagina, which, to many patients, 



DEVIATIONS OF THE PELVIC ORGANS. 481 

is a source of much discomfort ; besides, it is not always efficient 
in maintaining the uterus. It must be worn for months or even 
years to secure sufficient contraction to maintain the organ, 
consequently many patients prefer to submit to operative inter- 
ference. 

The pessary may be employed in retroversions due to sub- 
involution of the uterus subsequent to a recent delivery. In 
such cases the pessary will maintain the uterus at a higher 
level, promote the process of involution, and thus favor the 
maintenance of the organ in a replaced position, after it has 
reached its normal size. It may be employed after adhesions 
have been broken up, by the Schultze method, or when we 
have been able to accomplish the loosening of the uterus by 
pelvic massage. Where retrodisplacement has existed for 
some time, the posterior fornix of the vagina may be so shortened 
that the pessary can not be worn. Such a condition will re- 
quire treatment by douches and tampons until the posterior 
vaginal fornix is stretched. They are 
also of little value in those cases in 
which the vaginal portion of the cer- 
vix has been destroyed by amputa- 
tion or as a result of repeated labors. 
As the pessary is a foreign body, it 
is therefoi^, important that explicit 
directions should be given regarding 
its management before this subject 
is dismissed. Directions have been Fig. 38S.— Schultze's Sledge 
given for the determination of a Pessary, 

suitably sized instrument, and I 

would again emphasize the fact that the instrument should 
be neither too large nor too small. The former will cause 
pressure upon the surrounding parts, producing irritation, 
ulceration, loss of structure, and open avenues for the entrance 
of infection. A smaller instrument is easily dislodged from 
its position, does not serve any useful purpose, and may only 
serve to aggravate the condition. The patient should be directed 
to remove or have the instrument removed, if it gives rise to 
increased discomfort, and return to the physician within a 
week at least after its introduction. He can then determine 
definitely whether the instrument is serving its proper purpose 
or causing any irritation. In neurotic patients too much at- 
tention must not be given to the instrument, otherwise the 
patient will manufacture a long train of distressing symptoms 
and attribute them to its presence. The instrument is likely 
to increase the vaginal discharge, and for this reason it is im- 
portant that it should be kept clean. It is undesirable, how- 
31 




482 



GYNECOLOGY. 



ever, to employ mineral astringents in the douche for this 
purpose, as they are likely to become deposited upon the sur- 
face of the pessary, thus rendering it rough and, therefore, 
more likely to serve as an irritant. A properly fitting instru- 
ment can be worn by the patient without her being aware of 
its presence, but even though it causes no annoyance, the patient 
should be advised of the importance of having it removed at 
stated intervals, not exceeding three months, for cleanliness, 
and to make sure that it is producing no irritation. These 
rules^^apply to the hard-rubber instrument. Where the in- 







-^ 




^^ 


j 




mW*"" 


i 


i 






I^OUNP ^H 




B^llplLIO'iNGUIMALN. 


LiCMT. ^^ 


/ mM^Si^a 


^mm^^ 


r^ 


'^M 


V 



Fig. 



-Alexander Operation; Round Ligament Exposed. 



strument is of the soft -rubber variet3^ it should be removed much 
more frequently, as the discharges to some degree enter into 
the rubber, decomposition takes place, and a foul odor arises 
which is very annoying to the patient and to those with whom 
she is associated ; moreover, it may give rise to systemic infection. 
The operative procedures for the correction of retrodisplace- 
ments of the uterus consist of the extraperitoneal and intra- 
peritoneal shortening of the round ligaments, by abdominal 
or vaginal incision, and the construction of artificial ligaments, 
as in such operations as ventrofixation or ventrosuspension. 



DEVIATIONS OF THE PELVIC ORGANS. 



483 



Besides these, there are also numerous vaginal operative methods 
for connecting retroplaced uteri. 

Extraperitoneal Shortening of the Round Ligaments. — Shorten- 
ing of the round ligaments is an operation which was performed 
by Alexander in December, 1881, and two months later by 
Adams, although the latter contributed the first publication. 
The operation had, however, been advocated by a Frenchman 




Fig. 390. — Round Ligament Being Drawn Out. 



named Alquie, as early as 1840. The operation requires two 
incisions, and each consists of four stages: (i) An incision six 
centimeters long, a little inside the pubic spine and above 
and parallel to Poupart's ligament, is made through all the 
tissue to the aponeurosis of the external oblique (Fig. 389). 
(2) Exploration for the round ligament. This is disclosed by 
a small ball of fatty tissue which covers its end between the 



484 



GYNECOLOGY. 



pillars ot the external inguinal ring. Pressure upon the side 
causes the mass to protrude. A hook passed beneath this 
mass enables the operator to raise up the ligament (Fig. 390). 
It is then detached by a director, from the posterior adherent 
fibers which maintain its relation to the inferior part of the 
canal, after which it is seized with a pair of forceps and drawn 




Fig. 391. — Round Ligament Sutured. 



out. Upon the completion of the first and second stages, on 
both sides, we proceed to the third, which consists in shortening 
and fixation of the ligaments. The ligaments are drawn upon 
until the fundus is brought under the pubes. This movement 
can be facilitated and rupture of the fibrous filaments avoided 
by previously placing the uterus in antefiexion, either by the 



DEVIATIONS OF THE PELVIC ORGANS. 



485 



sound or preferably by the aid of the fingers of an assistant. The 
Hgaments are drawn out from four to ten centimeters, accord- 
ing to the resistance. When they become tense, they are main- 
tained by an assistant, while a needle charged with silk, silk- 
worm-gut, or catgut is made to traverse the external pillar, 
the ligament, and next the internal pillar (Fig. 391). Three 
sutures are thus introduced, one centimeter apart (Figs. 392 
and 393). (4) The wound is closed with silk or silkworm-gut 
sutures, dressed with 
gauze, and the parts 
are so secured by 
bandaging as to pre- 
vent the wound from 
becoming exposed by 
the movements of the 
patient. The employ- 
ment of a Hodge pes- 
sary for two months 
following the opera- 
tion is advisable, 
though some prefer 
the tampon. Various 
modifications of this 
operation have been 
devised. Edebohls 
splits the entire length 
of the inguinal canal, 
draws the ligaments 
out at the internal 
ring, and closes the 
wound as in the Bas- 
sini operation. New- 
man makes an inci- 
sion directly over the 
internal ring, draws 
the ligament straight 
out, and secures it in 
the wound. Franklin 

Martin and Buret, of Lille, do not use sutures, but pass a pair 
of dressing forceps beneath the skin and subcutaneous tissue 
from one wound to the other, draw the ligament through, tie 
the two ligaments together in a knot, and close the tissues over 
the union. Cassati joins the lower ends of the lateral wounds 
with a curved incision, in which the crossed ends of the Hga- 
ments are united by continuous suture. Doleris employs the 
same method, uniting the two ligatures with catgut sutures, 




Fig. 392. — Continuous Catgut Suture Uniting In- 
ternal Oblique Muscle to Poupart's Ligament. 



486 



GYNECOLOGY. 



after pulling them through, as in the method suggested by 
Martin. Goldspohn attempts to extend the usefulness of the 
Alexander operation by stretching the internal ring and open- 
ing through the peritoneum, so that the finger can be passed 
into the pelvis and break up adhesions about the uterus, ovaries, 
and tubes. By this method a tube or ovary can be withdrawn 
and subjected to necessary treatment. The advantages claimed 




R D.LI GMT. 



Fig. 393- — Return Layer of Suture Bringing External Oblique Muscle in 

Apposition. 



for the Alexander operation are: (i) The incisions being super- 
ficial or extraperitoneal, the risk of infection is less; as it is 
local, the danger of peritonitis is decreased; (2) the method of 
maintaining the uterus forward has less injurious influence upon 
a future pregnancy; (3) it imitates the natural support, in that 
the natural hgaments are employed; and (4) no intraperitoneal 
adhesions can form. The disadvantages are: (i) That two 



DEVIATIONS OF THE PELVIC ORGANS. 



487 



incisions are required. (2) The operation is limited in its ap- 
plication. It is only in those cases in which the uterus is mobile 
that we can practise this procedure. Consequently it has the 
further disadvantage in that we are not always able to deter- 
mine definitely the existence of adhesions between the uterus 
and the anterior wall of the rectum. Should such adhesions 
exist, the uterus drawn forward by the round ligaments is sub- 
ject to forces which tend to render the operation nugatory. 
The procedure of Goldspohn seeks to overcome this objection; 
nevertheless, the objection still remains, for the operation to 
break up adhesions and treat the pelvic organs is done through 
so small an opening as to render it more or less a blind proce- 
dure. Besides, severe injuries may occur and be readily over- 




ig- 394- 



-Wylie's Operation for Shortening the Round Ligaments within the 
Abdomen. 



looked. (3) The round ligaments are sometimes so attenuated 
as to be of little use in maintaining the organ. In an operation 
of mine, the ligament on one side was apparently entirely absent. 
I found no vestige of it in the canal. I therefore opened into 
the peritoneal cavity and found that the round ligament had 
disappeared. (4) In cases of infection the infected ligament 
may slip back .and carry infection beneath the peritoneum, 
where it will be difficult to reach, and, consequently, render the 
operation, as has been proved, not altogether free from danger. 

Intraperitoneal Shortening of Round Ligaments. — The round 
ligaments are shortened within the peritoneal cavity by making 
an incision through the abdomen in the median line. This 
procedure permits the uterus to be drawn up, the condition of 



488 



GYNECOLOGY 



the appendages examined and treated, if necessary. Existing 
adhesions can be broken up and the round Hgaments shortened 
by folding them (Fig. 394). Wyhe suggests that from two to 
four inches of the Hgament be doubled up on each side and united 




Fig. 395-- 



-Mann's Operation for Intra-abdominal Shortening of Round Liga- 
ments. 




Fig. 396. — Dudle3^'s Operation of Desmoi^ycnosis. 



by sutures, so that the shortened ligament draws and holds 
forward the fundus. Mann grasps the broad ligament about 
the junction of its middle and outer third and folds the ligament 



DEVIATIONS OF THE PELVIC ORGANS. 



489 



in three parts, which are united by sutures (Fig. 395). By this 
method the hgament is well shortened on each side. A. P. 
Dudley, of New York, performed an operation which he calls 




^i&- 39 7- — Dudley's Operation Completed. 

desmopycnosis (Fig. 396). This is accomplished as follows: 
The abdomen opened, an assistant introduces two fingers into 
the vagina and pushes the uterus as high as possible in the 
pelvis, while the operator brings the organ through the ab- 




Fig. 398. — Gilliam-Ferguson Operation. Round Ligament Seized through 

Stab Wound. 



dominal incision. An oval denudation is made upon the ante- 
rior uterine w^all, making sure that the bladder is not injured, 
then each round ligament is brought up to the portion of the 
peritoneal covering on the inner side, denuded to correspond 



490 



GYNECOLOGY. 



with that on the uterus, and the three denuded surfaces are then 
united with catgut sutures. The sutures must be so adjusted 
as to pass sufficiently deep in the uterine tissue to secure against 
their cutting out before union has occurred (Fig. 397). This 
procedure holds the uterus forward in a position of anteversion. 
Ries cuts a slit through the anterior surface of the fundus, 
through which a loop of the round ligament, drawn out of its 
sheath, is carried and fastened on either side. Webster picks 
up a loop of the round ligament, carries it through the broad 
ligament beneath the Fallopian tube, and secures it to the pos- 




Fig. 399. — ^ Round Ligament Drawn through the Abdominal Wall. 



terior surface of the uterus. This procedure has been modified 
by Baldy, who ligates the uterine end of the round ligaments, 
incises the ligaments external to the ligature and carries the 
free end, rather than the loop, through the broad ligament and 
fastens it to the posterior surface of the uterus. All these opera- 
tive procedures, however, act upon the strongest part of the 
ligament, leaving the weakest portion to be stretched out. 
Gilliam and Ferguson have devised a procedure (Fig. 398) which 
consists in picking up the ligament, three or four centimeters 



DEVIATIONS OF THE PELVIC ORGANS. 



491 



from its uterine end, and carrying a loop of it through a stab 
wound in the lower part of the rectus muscle on either side, 
and there securing it (Fig. 399). The peritoneal surface just 
within the ligament has been previously quilted together by a 
ligature, which is brought out near the peritoneal edge of the 
wound. This, when tied, closes up the gap in the peritoneal 
cavity external to the point through which the loop of the liga- 
ment is brought out. With these parts secured, the uterus is 
held forward by a loop of the strongest part of the round liga- 
ment, and affords what seems to be an ideal method of main- 
taining the uterus in an anteflexed position (Fig. 400). 




Fig. 400. — Section showing Position of the Uterus with Completion of the 

Operation. 



Ventrofixation and Ventrosuspension. — These terms are ap- 
plied to the operation devised by Olshausen and modified by 
Kelly, for establishing an artificial ligament for the purpose of 
maintaining the uterus forivard. The operation consists in an 
incision in the median line, through which the uterus is exposed 
and its fundus sutured to the parietal peritoneum at the lower 
angle of the wound Two or three buried sutures of silk, silk- 
worm-gut, catgut, or silver wire are generally employed (Fig. 
401). The first suture is passed through the peritoneum about 
one centimeter from the wound margin, through the fundus 
uteri near its center, and brought out through the peritoneum 



492 



GYNECOLOGY. 



of the Opposite side of the wound. A second suture is similarly 
placed about eight millimeters behind the first. To prevent 
the peritoneum from being dragged away from the abdominal 
wall, it is included in the abdominal suture. Since the first 
edition of this book, I have modified my method of performing 
this operation, by introducing a silkworm-gut suture through 
the fundus of the uterus and the abdominal walls, which is tied 
externally. Then a needle, carrying a chromic catgut suture, 
is introduced through the aponeurosis of the lower angle of the 
right side, through the fundus of the uterus, near the silkworm- 
gut suture, and brought out through the peritoneum of the oppo- 
site side. Two subsequent turns of the suture are passed through 





/// 







Fig. 401. — Sutures Introduced for Ventrosuspension. 



the edges of the peritoneum and the fundus of the uterus, after 
which the peritoneal wound is closed with the remaining portion 
of the suture. Following the introduction of silkworm-gut 
sutures through all the tissues above the peritoneum, this same 
catgut suture is carried back through the aponeurosis and tied 
at the lower angle of the wound. Therefore the uterus, peri- 
toneum, and aponeurosis are all held by the one suture, and only 
a single buried knot remains in the incision. The silkworm-gut 
sutures are then tied, which bring in apposition and secure the 
skin-edges. The stay suture, or lower suture of silkworm-gut, 
is removed about the tenth day. This operation establishes a 
ligamentous band between the uterus and parietal peritoneum. 



DEVIATIONS OF THE PELVIC ORGANS. 493 

which is sufficiently strong to maintain the uterus forward and 
yet not interfere with its mobihty. Where it is preferable — as, 
for instance, after the climacteric, or in patients from Avhom both 
ovaries have been removed— that the uterus should be more 
firmly fixed to the abdominal wall, it is better that the perito- 
neum should be pushed back so that the sutures bring the muscle 
structure directly in contact with the fundus of the uterus. 
Such a course secures a firmer union and, therefore, the uterus 
is held more closely to the parietal wall. The procedure w^e have 
described permits thorough exploration of the pelvic cavity, 
the separation of adhesions, and the fixation of the uterus 
through a single incision. The procedure has been greatly 
modified. By some, the sutures are placed in the anterior uterine 
wall. The majority of operators insert them in the fundus, 
the first suture in the line of the Fallopian tubes, and the second 
a little behind it, thus throwing the uterus forward in slight 
anteflexion. The purpose of the operation of ventrosuspension 
is to establish a ligamentous union, which will permit a certain 
amount of uterine mobility. Consequently the uterus is attached 
only to the peritoneum, rather than to the muscle wall. To 
avoid the buried suture, F. ^lartin has suggested using the 
urachus, and w^hen it is not well defined, a loop of peritoneum 
is carried from below upward through a buttonhole slit in the 
fundus and included in the sutures closing the wound. Bovee 
employs a portion of muscle aponeurosis. These modifications, 
however, have no special advantage. The fixation has been 
accomplished through a transverse incision above the symphysis. 
This incision only divides the skin and superficial fascia. A 
vertical incision is then made through the aponeurosis, muscle 
wall, and peritoneum. The uterus is brought forward and se- 
cured by two silkworm-gut sutures through the fundus. These 
are brought out through the muscle wall and segment of integu- 
ment below the transverse incision. The remaining portion of 
the vertical w^ound is closed with catgut and the transverse in- 
cision in the skin Avith a continuous intercuticular stitch of silk. 
The suspensory stitches are tied over a gauze roll and permitted 
to remain two weeks. Ventrosuspension has the advantages 
already suggested, that it permits the inspection of the con- 
dition of the peritoneal cavity, the treatment of diseased appen- 
dages, the separation of adhesions, and the fixation forward of 
the uterus in a position which is unlikely to give distress. It has 
the following disadvantages : f i ) That it has been found to inter- 
fere to some degree with subsequent gestation and labor, the 
patient complaining of more or less pulling and distress during 
the progress of gestation, sometimes so marked as to cause abor- 
tion or premature labor. AYhen the b?.nd of fixation is short, large, 



494 GYNECOLOGY. 

and firm, it may prevent enlargement of tlie uterus and produce 
thinning of the posterior wall, which will increase the danger 
of rupture and afford obstacles to the normal progress of par- 
turition. A firm band of adhesion, during pregnancy, after the 
performance of ventrofixation, may cause a condition simulating 
a bifid uterus. I have, in three instances, opened the abdomen 
during pregnancy and cut the band in order to permit the 
uterus to properly develop. Furthermore, I have seen several 
instances in which I felt that such a procedure was advisable. 
In one instance I was called in consultation to see a woman 
who had had a ventrosuspension performed and who was in 
labor at full term. The anterior wall of the uterus and cervix 
were apparently doubled up, forming a shelf upon which 
the fetus rested with an arm protruding. The attendants, 
after vigorous efforts to turn the child, had cut off this arm. 
The fetus was lying in a transverse position, and a part 
of the body had engaged. After considerable difficulty I suc- 
ceeded in passing a cephalotribe upon the body of the child, 
with which I crushed the spine and delivered first the lower ex- 
tremities, and then the trunk and head. (2) That the operation 
is not free from danger. I had the misfortune to have one 
patient in whom a large portion of intestine slipped below the 
band of adhesion immediately following the operation. This 
became strangulated and caused death. Similar cases have been 
reported by Lindfors, Jacobi, Olshausen, and others. The 
accident in my case occurred almost immediately after the 
operation, and, although the patient suffered greatly, it was 
attributed by her attendants to hysterical excitement following 
the anesthetic, and, when recognized, the condition of the 
patient was such as to preclude any hope of recovery. It would 
not require great stress upon the imagination, when one sees 
these bands of adhesion, to appreciate the possibility of strangu- 
lation occurring at periods more remote from the operation, 
and numbers of such instances are recorded. (3) The buried 
sutures of silkworm-gut, silk, or silver wire may become a source 
of irritation, either from immediate infection or later inflamma- 
tory changes, and cause a sinus to extend through the abdominal 
wall and give rise to an unpleasant discharge. Such a sequence, 
of course, annoys both patient and surgeon until the offending 
cause — the buried sutures — have been removed or have become 
disintegrated. Such a sinus may keep up for months or even 
years. The sutures can occasionally be fished up and removed. 
For this purpose I know of no instrument better adapted than 
the hook of the ear spoon devised by the elder Gross for the 
removal of hardened wax from the ear. If this instrument is 
ineffective, the surgeon may find himself obliged to reopen the 



DEVIATIONS OF THE PELVIC ORGANS. 495 

wound, and frequently the offending ligature will be found deep 
in the pelvis, at the end of the band of adhesion. For the pur- 
pose of avoiding this difficulty, I have employed the chromic 
catgut suture with a single knot. Burrage has advised ventro- 
fixation for the treatment of immobile anteflexion. Through 
an abdominal incision he divides the uterosacral ligaments close 
to the uterus and secures the fundus to the abdominal wall. 
Schmidt, of Cologne, frees the anterior uterine wall from the 
bladder by dissection, excises a wedge-shaped piece with its 
point directed toward the cervical canal, and unites the surfaces 
by sutures. This draws the uterus forward in a position of 
anteflexion. 

Vaginal Operations. — The ease with which the pelvis can 
be entered through the vagina has led to the adoption of various 
operative procedures through this canal for the purpose of 
maintaining the uterus in proper position. One of the earliest 
operations performed through the vagina is that known as the 
Schticking. This consists in passing an instrument, curved, 
for an acute anteflexion, to the fundus, from which a concealed 
needle is driven through the anterior vaginal fornix. This needle 
carries back the ligature, which, when tied, fixes the uterus in a 
position of anteflexion. Care must be exercised in its employ- 
ment to avoid injuring the bladder by pushing this organ to one 
side. Injury of the intestine has also occurred. The ligature 
is permitted to remain for two or three weeks, when the resulting 
inflammatory changes will maintain the uterus in an anteflexed 
position. The procedure is objectionable, in that it is a blind 
operation, and injury, therefore, may be unavoidable. In- 
struments have been devised to push the uterus against the 
anterior abdominal wall and thrust needles carrying ligatures 
from its cavity, by which the fundus can be fastened ; but these 
are open to the objection already assigned — that theyjare blind 
procedures. Vaginal fixation devised by Duhrssen, subse- 
quently practised and modified by Mackenrodt, consists in 
making a vertical incision through the anterior vaginal wall to 
the cervix, when the bladder is pushed off until the peritoneum 
is reached. Without opening the latter, a suture is introduced, 
and by it the uterus is pulled forward. A second suture, placed 
higher, near the fundus, is employed to maintain the uterus 
forward by bringing its ends through the edges of the vaginal 
incision. Mackenrodt modified the operation by opening through 
the peritoneum and introducing the sutures at a higher level, 
thus securing the fundus or anterior wall to the vaginal incision. 
The peritoneal and vaginal wounds were then closed. This 
operation for a time was very largely practised, but it was soon 
recognized that it was likely to cause much distress and discom- 



496 GYNECOLOGY. 

fort during the progress of gestation. Moreover, it often pro- 
duced profound dystocia, which imperiled the Hves of both 
mother and child. For these reasons, the operation is now 
rather infrequently practised. Vineberg and Wertheim, through 
a similar incision, seize the round ligament some three centi- 
meters from the fundus uteri, pass a ligature beneath it, and 
bring the ends of this ligature out through the vaginal walls on 
either side of the vertical incision. The ligature is then tied. 
This holds the round ligament down against the vagina, and, 
consequently, fixes the uterus forward. The round ligaments 
have also been shortened through the vagina by performing 
the Wylie or Mann operation upon them. I have sutured the 
round ligaments to the anterior surface of the uterus through 
the vaginal opening. The operation of Ries consists in pulling 
a loop of the round ligament through a slit in the anterior wall 
of the uterus. This method has been described under abdominal 
procedures, but was devised to be performed through the vaginal 
incision. Through a posterior colpotomy by a vertical incision, 
Freund and Gottschalk shortened the uterosacral ligaments. 
The incision was made from just behind the cervix downward, 
toward the rectum. The peritoneal cavity was opened and a 
ligature introduced on each side to separate the surfaces. From 
this opening, a ligature was carried through the middle of the 
uterosacral ligament and one end of it through the posterior 
surface of the cervix. The ligature thus introduced on each side 
was tied, which drew the cervix upward and backward. Con- 
sequently, the other end of the lever, the fundus, was thrown 
forward. Pry or advocates a transverse incision in the posterior 
fornix of the vagina, through which he breaks up adhesions, 
carries the uterus forward, and packs gauze into the posterior 
culdesac. Then with a tampon he presses the cervix well up- 
ward and backward. The subsequent adhesion of the cervix in 
this position leads to correction of the malposition. 

443. Lateral Flexion.— Lateral uterine bending may be dex- 
troflexion or sinistroflexion. The position of the cervix is more 
or less fixed and the fundus of the uterus is drawn to one side 
by cicatricial contraction, or is pushed to the opposite by a large 
exudate, an intraligamentary fibroid growth, or an ovarian cyst. 
No special symptoms characterize the state; the diagnosis is 
readily determined by the methods already cited for the deter- 
mination of other forms of displacement. 

444. Complications Associated with Displacements. — It has 
been noted, in discussing the individual forms of displacement 
of the uterus, that they rarely produce symptoms themselves, 
and, when it is considered that the organ involved, in its normal 
condition, weighs less than an ounce, that its circulation is so 



DEVIATIONS OF THE PELVIC ORGANS. 497 

extrinsic that the organ can be bent forward or backward with- 
out injury thereto, it is difficult to see why so much stress has 
been placed upon these deviations. 

The development of a complication, however, by which the 
circulation is obstructed, changes the whole aspect of affairs. 
The most frequent complications of uterine displacements are : 

Endometritis. 

Metritis. 

Salpingitis. 

Oophoritis. 

Cellulitis. 

Peritonitis. 

Other complications are: 

Ectopic gestation. 

Ovarian or myomatous tumors. 

Ptosis of the abdominal viscera. 

These complications are most frequently primary as regards 
the production of symptoms, though, as in prolapsus, they may 
be secondary in the sense that the displacement lessens the 
resistance to infection. 

445. Prognosis of Displacements. — The prognosis of a dis- 
placement will depend upon its degree and the existence of 
complications. In the earlier stage of the displacement, when 
the distress arises from increased weight of the organ, the mere 
correction of the position and the maintenance of the organ 
corrected will bring about a decrease in its size and afford relief 
from the displacement. After the displacement has existed for 
some time, it is complicated by chronic inflammatory changes, 
which will absolutely prevent any procedure from maintaining 
the organ in its proper position. The symptomatic phenomena, 
however, can be relieved and the patient be practically restored 
to health. 

446. General Treatment. — It will be seen, from a discussion 
of the different forms of displacement, that I am disinclined to 
believe that uncomplicated displacements are likely to produce 
symptoms. Of course, I can readily understand that when a 
patient has prolapsus, with the uterus protruding from the 
body, it necessarily produces disturbance and is subject to 
unusual irritation from its abnormal location. The small size 
of the uterus, when normal, the manner in which it receives and 
discharges its blood-supply, render it difficult to conceive how 
the mere displacement of so movable an organ should be pro- 
vocative of the serious symptoms which have been frequently 
attributed to it. The most frequent complications of uterine dis- 
placement are inflammatory processes and their sequelse, which 
cause increase in the size of the organ, its fixation bv extensive- 

32 



498 GYNECOLOGY. 

adhesions, and interference with the performance of the function 
of the adjacent viscera. The treatment, then, must largely 
consist in the correction of the existing complication. Expe- 
rience has disclosed, however, that when such complications 
exist, their treatment is most effective when associated with 
measures directed to maintain the uterus in proper position. 
The methods of procedure most effective to accomplish this 
purpose are both local and constitutional, such as massage, 
electricity, and mechanical procedures. The patient should be 
suitably clad, and wear clothing free from undue constrictions 
about the waist. Her skirts should be supported from the 
shoulders. The bowels should be carefully regulated, and the 
bladder should not be permitted to become over distended. The 
existence of periuterine inflammation and extensive exudates 
can be ameliorated and absorption expedited by the employ- 
ment of pelvic massage. This is best performed by a daily 
seance of five to ten minutes or more, after the more severe 
distress and pain have been relieved. The vault of the vagina 
may occasionally be painted with tincture of iodin, and in the 
intervals between the massage, tampons medicated preferably 
with an antiseptic solution containing glycerin should be worn. 
The tampon maintains the uterus at a higher level, promotes 
the absorption of exudation, facilitates involution, and thus 
favors its maintenance in a normal position. Vaginal douches, 
hot rectal enemata, hot sitz-baths, or the application of heat 
over the abdomen or pelvis in the form of hot sand or a peat 
bath will be found beneficial. Pressure over the abdomen, 
particularly where a mass of exudate is recognized, will promote 
its absorption. This action oftentimes causes such an exudate 
to entirely melt away. The pressure can be effected by the use 
of a shot bag, by which three to five pounds or more of shot are 
retained over the affected surface. When the uterus is freely 
movable or the adhesions have been absorbed, the organ can 
be maintained in its proper position by a suitable pessary. It 
should, however, be recognized that the physician must be able 
to replace the uterus in its proper position before employing this 
instrument. The pessary does not act as a corrective agent, 
but only as a crutch to support and maintain the uterus in its 
corrected position. The pessaries are generally made of soft 
and hard rubber, sometimes of wire coated with soft rubber. 
The soft -rubber instruments absorb the discharges from the 
vagina, decompose, become exceedingly foul, and cause a very 
disagreeable odor. During the time the pessary is worn it is 
important that the vagina should be daily irrigated. Solutions 
of the inorganic salts should not be employed for irrigation, for 
they are likely to become deposited upon the surface of the 



DEVIATIONS OF THE PELVIC ORGANS. 499 

pessary, cause it to be rough, and thus lead to abrasion and 
ulceration. Care must be exercised in the employment of the 
pessary that it shall not be either unduly large or too small. An 
overlarge instrument makes pressure upon the surfaces of the 
vagina, causes ulceration and the formation of granulations, 
which may envelop a large portion of the pessary and finally 
cause it to become embedded in cicatricial tissue. Too small 
an instrument permits the uterus to fall back over the pessary, 
or the pessary itself to be twisted around and thus prevent it 
being of any service. 

447. Summary. — In anteversion and anteflexion of moderate 
degree, constitutional measures for the improvement of the 
general health, the regulation of the secretions, enforced rest 
during menstruation, with dilatation, curetment, and the estab- 
lishment of proper drainage will be means sufficient to establish 
a symptomatic cure. When the anteflexion is acute and dys- 
menorrhea is marked, curetment will generally be of only tem- 
porary beneflt and should be followed by splitting the posterior 
lip and suturing the surfaces as advised by E. C. Dudley. Retro- 
version and retroflexion are capable of producing marked influ- 
ence upon the general health, but should not be considered 
as indicating the practice of special procedures unless they are 
productive of symptoms. The correction and maintenance of 
the uterus in its proper position is indicated as a preliminary 
treatment of any complication, and retroversion, associated 
with subinvolution following a recent parturition, unless com- 
plicated by perimetritic adhesions, should be considered an 
indication for the use of the pessary, but the previous replace- 
ment of the organ must be a sine qua Jioii. In retroflexion, if 
the pessary is not well borne and the uterus is freely movable, 
the Alexander operation may be employed. The great frequency 
with which inflammation and more or less adhesion of the uterus 
occurs greatly limits the number of cases to which this operation 
is applicable. Indeed, I would prefer to make the median incis- 
ion, for it enables us to thoroughly examine the condition of 
the pelvic viscera, to break up existing adhesions, and to treat 
diseased conditions of the ovaries and tubes. As already seen, 
the great majority of operations for shortening the round liga- 
ments within the abdomen utilize the strongest portion of the 
ligament and leave the weakest undisturbed, with the probability 
of a redevelopment of the condition. The operation devised by 
Gilliam and Ferguson seems to me the most desirable, as it 
accomplishes all that the Alexander operation could do. ]\Iore- 
over, it has the advantage over the operation of ventrosuspen- 
sion in that it aft'ords no opportunity for the formation of adhe- 
sions which may serve as a trap by which a knuckle of intestine 



500 GYNECOLOGY. 

may become fixed and obstructed. My experience leads me to 
the performance of the operation known as ventrosuspension 
or ventrofixation less and less frequently. Of the vaginal 
operations, the one devised by Vineberg is the most serviceable. 
The other vaginal operations have proved unsatisfactory, for 
many of the patients thus operated upon have experienced 
trouble during a subsequent pregnancy. Prolapsus uteri is a 
condition which should receive early consideration. The longer 
the displacement is permitted to remain unantagonized, the 
greater are the chances that it cannot be completely restored. 
The first stage of uterovaginal prolapse can be corrected by the 
employment of a suitable pessary. One should be employed 
which will maintain the uterus in a position of anteflexion or 
anteversion. The early stage of vagino-uterine prolapse should 
be considered an indication for the prompt retraction of the 
relaxed vaginal walls and the restoration of the perineum. The 
accompanying cystocele should be treated by an excision of the 
redundant vaginal portion of the septum. This surface should 
be sutured in a transverse direction in preference to the suture 
that is sometimes advocated, known as the Stolz suture, which 
shortens the vagina in every direction. The importance of 
having a long anterior vaginal segment is seen in its influence in 
maintaining the cervix at a higher level, consequently throwing 
the fundus forward. In the later stages of prolapsus, the vaginal 
plastic operation should be supplemented by an abdominal pro- 
cedure to maintain the organ forward. This may be accom- 
plished by shortening the round ligaments. After the climac- 
teric, especially when the uterus shows a marked tendency to 
descent, fixation of the organ is desirable. In very extensive 
prolapsus or in elongation of the supravaginal cervix the fundus 
uteri should be amputated, and the stump can then be secured 
to the upper part of the broad ligament or to the anterior 
abdominal wall. Very frequently the condition will be compli- 
cated by an extensive hernia through Douglas' pouch, when an 
extensive vaginal plastic operation, combined with a ventro- 
fixation, will not necessarily prevent the development of this 
condition. The hernia may be obviated, however, by suturing 
together the fold of Douglas over the rectum and the remaining 
part of each fold to the side of the rectum. Enteroptosis may 
be still further prevented by fastening the colon to the abdominal 
parietes. My experience has led me to condemn the Freund 
operation as one of no value. 

448. Inversion of the Uterus.— Inversion of the uterus is 
that condition in which its inner or mucous surface is outside 
and its internal or peritoneal surface within. Inversion can 
be partial or complete, and presents three different degrees: 



DEVIATIONS OF THE PELVIC ORGANS. 



501 



In a partial inversion the body of the organ is depressed and 
inverted until it reaches the cervix, but without dilating the 
latter, when it is known as the first degree, or inversion intra- 
uterine (Fig. 402). Next, the fundus protrudes through the 
cervix, the cervix being turned down upon the neck like a cuff, 
which is the second degree, or inversion intravaginal (Fig. 
403). In the third degree the entire uterus is inverted, and 
with it, not infrequently, the vagina, the uterus hanging outside 
the vulva, and this is known as inversion extravaginal (Fig. 
404). Now, every degree of this form of alteration of the uterus 
can combine itself with a partial or total inversion of the vagina 





Fig. 402. — Partial Inversion of the 
Uterus, showing Three Degrees. 



Fig 403. — Intravaginal Inversion 
Three Degrees. 



SO the view that the third degree only is necessarily combined 
with prolapsus is a mistake. A trifling degree of inversion or 
partial turning in of the uterus is called invagination. This may 
be a mere depression, over which the mucous surface becomes 
convex, while the peritoneal surface forms a depression or con- 
cavity. As this depression continues, the proximity of the tubes 
and round ligaments to the ligamentum ovarium draws these 
structures into the opening. The ovaries may rest upon the 
funnel-shaped depression, while the tube is necessarilv, for a 
part of its extent, drawn into the cavity. The cavity, with its 



502 



GYNECOLOGY. 



enlarged opening in the peritoneal cavity, is called the inversion 
funnel. This funnel is usually not quite the depth of the ordinary 
length of the uterine cavity. If the inversion continues for 
some time, secondary phenomena result, from retrogressive 
processes, but the uterus returns to its normal size. The in- 
verted mucous membrane is covered with epithelium; the neck 

of the uterus is small, generally sur- 
rounded by a cuff of tissue, derived 
from the cervix, which has not been 
completely inverted — a cervical ring. 
The longer the inversion exists, the 
more considerable is the congestion, 
edematous enlargement, and thicken- 
ing, which form the misproportion 
between the narrow inversion funnel 
and the enveloping cuff of the cer- 
vix. We not infrequently find dis- 
eases of the adnexa. The orifice of 
the tube situated in the vagina can 
readily be the avenue for the passage 
of infection into the deeper struc- 
tures. The uterine inner surface of 
the tubal mouths is exposed, the 
projecting mucous membrane is fre- 
quently rubbed and irritated, so this 
door stands open for the entrance of 
germs, and infection can take its way 
through the tubal mucous membrane 
or by the lymphatics to the deeper 
tissues, producing endosalpingitis, 
suppurative processes in the ovary, 
or purulent pelvioperitonitis by ex- 
tension of infection from the connec- 
tive tissue. In ordinary conditions 
we can have involvement of the cel- 
lular tissue from such infectious pro- 
cesses. Alterations in the peritoneal 
covering of the inversion funnel oc- 
cur, which render the condition more 
or less fixed. 
449. Etiology. — Inversion generally arises from, two causes : 
first, from puerperal conditions, relaxation, or partial paralysis 
of the uterus during the process of labor, especially the third 
stage of labor; and, second, the nonpuerperal form, in which 
the uterus is displaced by the presence of a fibroid tumor at- 
tached to the fundus. (Fig. 405.) These two conditions are 




Fig. 404. — -Extravaginal In 
version; Three Degrees. 



DEVIATIONS OF THE PELVIC ORGANS. 



503 



very much alike in the cHnical form of an inversion, but are 
very different in their manner of development. Puerperal 
inversions are much more frequent than those which arise from 
the presence of growths. They are m the proportion of nine to 
one. Total inversion is rare. How much more frequently the 
partial form occurs is difficult to determine, as not infrequently 
partial inversion resulting from the presence of grow^ths is over- 
looked. Puerperal inversion, in some cases, is produced by 
traction upon the cord in the 
efforts to deliver the placenta ; 
by faulty pressure over the 
uterus the fundus may be in- 
verted, and in the paralyzed 
condition may be grasped by 
the deeper structures and the 
inversion progress until it is 
completed. A short cord is an 
occasional cause for inversion. 
When the ominous traction is 
made upon the cord, the uterus 
is relaxed. The traction upon 
the fundus, and the subsequent 
uterine contraction, can more 
rapidly effect the displacement. 
Inversion rarely occurs sponta- 
neously. The overdistention of 
the cervix by a large fetus fre- 
quently causes such relaxation 
as will permit inversion to occur 
readily. It will be a matter of 
interest to know whether, in the 
cases in which inversion has 
occurred, the placenta has been 
attached near the fundus of the 
uterus. 

450. Symptoms. — Inversion 
causes characteristic symptoms. 
The patient generally complains 
of severe pain, which is con- 
tinuous, sometimes for days; sometimes a pulling sensation is 
felt in the vagina. Immediately following the dislocation a 
severe hemorrhage occurs. This continues in noteworthy 
strength the first day of the puerperium, and does not completely 
disappear, but may continue much longer. Later, it appears 
intermittent, but the suspension of discharge rarely corresponds 
in its duration to the normal intermenstrual interval. During 




405.- 



■Xonpuerperal Inversion. 
Fibroid Tumor Attached to the 
Fundus Uteri. 



504 



GYNECOLOGY. 



the interval there is a profuse mucous discharge from the geni- 
talia. The profuse blood discharge can cause the death of the 
patient from acute anemia, or later from septic infection. In 
some cases spontaneous reinversion may take place in the course 
of the year. The condition may be suspected from these phe- 
nomena. 

451, Diagnosis. — Inversion will be suspected from the severe 
pain, the more or less continuous hemorrhage, and the absence 
of the fundus uteri when the hand is placed upon the abdomen. 
Digital examination discloses a globular mass which fills up the 




Fig. 406. — Palpation of an Inversion of the First Degree. 



vagina and is encircled by a cuff-like ring at its upper part. 
This ring is situated at the external os. (Fig. 407.) Placing 
the hand over the abdomen and making deep pressure, the fundus 
of the uterus is found to be absent from its normal situation, 
and, instead, a funnel-shaped excavation is recognized, which is 
ordinarily sufficient to determine the diagnosis. (Fig. 408.) 
In the chronic condition the uterus resumes its normal size, 
presents a globular or pear-shaped mass in the vagina, sur- 
rounded at its upper part by a distinct cuff or ring, and the sound 



DEVIATIONS OF THE PELVIC ORGANS. 



505 



will pass into this the same distance on all sides. Bimanual 
examination discloses above, a funnel-shaped depression. This 
depression can be more readily determined by drawing upon the 
fundus of the uterus and introducing the finger into the rectum, 
when it can pass over the neck and directly into this funnel. 
The ovaries and tubes are recognized near it or upon its margin. 
By investigation with the speculum the vaginal tumor is smooth, 




Fig. 407. — Palpation of an Inversion of the Second Degree. 



glistening, highly reddened and sometimes at its lower angles 
the openings of the tubes can be recognized. While a vaginal 
examination may afford a suspicion of the character of the dis- 
order, the diagnosis is incomplete without a bimanual investi- 
gation which involves the rectum and belly cavity. When the 
abdominal walls are very thick and palpation is not readily 
determined, the introduction of a sound or a catheter into the 



506 



GYNECOLOGY. 



bladder and of a finger into tlie rectum enables us to determine 
definitely the presence or absence of the uterine body. Inver- 
sion of the uterus is sometimes confounded with fibroid polypus 
which has been extruded into the vagina. (Fig. 409.) A fibroid 
polypus may have a broad-based pedicle and the tumor may 
present a shape very similar to that of an inverted uterus. As it 
is covered with mucous membrane the superficial similarity may 
be marked. Of course, a fibroid tumor will show no orifice of the 




Fig. 40S. — Appearance of Inversion of the Third Degree. 



Fallopian tubes, but the latter are not always distinguished. 
Sensation in the fibroid is a little less marked than in the inverted 
uterus, but is not sufficiently definite to afford a foundation for 
diagnosis. The sound carried around the cuff of the inverted 
uterus passes on all sides an equal distance. With fibroid tumor 
it would pass into the uterine cavity at one side. (Fig. 409, b.) 
Occasionally, however, the cavity of the uterus may be so stenosed 



DEVIATIONS OF THE PELVIC ORGANS. 



507 



that the sound will not enter, and the diagnosis may then be 
uncertain. (Fig. 409, c.) 

If we grasp the mass and draw it down, the finger in the rec- 
tum will disclose, in the one case, the cup-shaped depression of the 
inverted uterus; and, in the other, the body of the uterus lying 
above the neck of the growth. In a partial inversion, associated 
with fibroid growth, we may not be able definitely to determine 
the condition until we proceed to operation for the removal of 
the mass. (Fig. 410.) 

452. Treatment. — There is a difference in the treatment of 
the two forms of inversion. In the puerperal condition all that 






Fig. 409. 



Inversion of the Uterus, b Fibroid Polypus, 
pus, with Stenosis of the Cervical Canal. 



Fibroid Poly- 



is necessary is to replace the uterus, when it will remain, while 
in the nonpuerperal form it is necessary to remove the growths 
which have occasioned it. Reinversion is comparatively easy in 
recent cases. Pressure against the fundus with the hand or 
fingers in the shape of a cone will be frequently sufficient to carry 
the hand directly into the cavity of the uterus and to accomplish 
its complete reinversion. After the puerperal condition be- 
comes chronic we then have to resort to various methods for re- 
placement of the organ. These methods consist in manual 
treatment — instrumental and operative. In the manual treat- 
ment the fingers exercise a veritable taxis on the inverted organ, 



508 



GYNECOLOGY. 



just the same as in hernia, and the two hands are necessary for 
treatment, in which they play an essentially distinct role. The 




Fig. 410. — a. Submucous Fibroma, b. Partial Inversion, c. Partial Division 

of the Uterus. 




Fig. 411.— Prolapsus Uteri without Inversion. 

left hand over the abdomen maintains the uterus, while the 



DEVIATIONS OF THE PELVIC ORGANS. 



509 



right replaces the inversion. Courty introduces one or two 
fingers into the rectum and hooks them over the end of the 
uterus, which fixes it more soHdly. The other hand is intro- 
duced partly or totally into the vagina. The method of taxis 
is exercised in various directions; thus, it is central, lateral, or 
peripheral. The taxis is called central when the pressure is made 
against the fundus, or median part of the organ (Fig. 413); 
lateral when it is exercised at the level of one or the other uterine 
cornu (Fig. 414) ; and peripheral when the pressure is exerted on 
the reflex parts (Fig. 415). The latter is exemplified when w^e 
grasp the fundus in the palm of the hand, pass the fingers to the 
fundus of the vagina, and spread it out, stretching the funnel 




Fig. 412. — Inversion of the Uterus — Extravaginal. 



while the fundus is pushed against it. If taxis has been tried 
and found inefficient, we can then resort to instrumental reduc- 
tion. A number of instruments for this purpose have been de- 
vised. The air pessary of Gariel is introduced and distended. It 
exerts a hydrostatic or aerostatic pressure against the fundus, and 
pushes it upward, while the vaginal walls, by their traction, pull 
apart the cervix. This soft pressure in some cases may be sufii- 
cient to accomplish the gradual reduction of the organ. The 
pessary can be introduced and the bandage so applied as to 
maintain the pressure against the cervix (Fig. 416). A vaginal 
tampon of iodoform gauze for twent3'^-four hours is sometimes 



510 



GYNECOLOGY, 



more| effective than the pessary. The pressure is sometimes 
employed against the fundus by having an instrument with a 
cup-shaped end, into which the fundus fits, and a spring upon 
its external surface by which an elastic pressure is induced. 
(Fig. 417.) This procedure is more effective when combined 
with Marcy's suggested insertion of two or more ligatures in the 
cervix, by which traction can be made upon it, while pressure 
is made against the fundus. Thomas advised opening the abdo- 
men and dilating the cervix with an instrument similar to a 
glove-stretcher, while pressure is made against the fundus. 




Fig. 4 13. ^Central Taxis. 



(Fig. 418.) This procedure was successful in one case and fatal 
in another. It has been suggested to introduce the index-finger 
of one hand into the rectum, and that of the other into the blad- 
der, hooking them into the funnel-shaped depression of the 
uterus, while the thumbs are pressed against the fundus. Klist- 
ner advocates making a transverse incision through the posterior 
fornix of the vagina into Douglas' culdesac, through which he 
presses the index-finger of the left hand into the inversion funnel, 
and attempts with the thumb of the same hand to press up the 
fundus. If the procedure fails, he advises splitting through the 



DEVIATIONS OF THE PELVIC ORGANS. 



511 



posterior uterine wall, in the median line, by a longitudinal in- 
cision, which may extend to within two centimeters of the fundus, 
from the mucous surface to the peritoneal. (Fig. 419.) The 
renewal of attempts at reinversion under such circumstances is 
usually successful, for the reason that the resistance is removed 
and we are consequently enabled to replace the organ. After 
the uterus has been reinverted the fundus is turned down through 
the vaginal opening and a number of sutures are introduced to 
close the incision. Hirst advises a cut through the vaginal por- 
tion of the cervix only. Cases have been recorded of spontane- 
ous reduction of the inversion when the vulva has been distended 




Fig. 414. — Lateral Taxis. 



with the patient in the genupectoral position. If the conditions 
are unfavorable for an operation of reinversion, we can proceed 
to total extirpation of the uterus or to amputation of the inverted 
fundus. When the amputation of the fundus only is made, it is 
very important to guard against reinversion of the stump with a 
resulting hemorrhage into the peritoneal cavity. The stump may 
be secured by three or four partial ligatures, and then the ampu- 
tation may be made below them. When the inversion is pro- 
duced by the presence of tumors, we may content ourselves 
simply with the removal of the growths and the reinversion of 
the organ; or when the organ is very extensively involved, it 



512 



GYNECOLOGY, 



may be necessary to remove the fundus with the growth. The 
possibiHty of partial inversion should always be kept in mind 
in operating upon partial extrusion of growths from the uterine 
cavity. Numerous cases are recorded in which a fibroid polypus 
or growth has been removed by the wire ecraseur, and examina- 
tion subsequently disclosed that a portion of the uterine wall was 
removed, causing an opening into the abdominal cavity. With 
growths projecting into the vagina, the preferable procedure is 
a careful enucleation of the tumor. The tumor is depressed and 




Fig. 415. — Peripheral Taxis. 



held while the enucleation is performed under the eye, so that, 
even though an inversion has occurred, by hugging the tumor 
closely we prevent breaking through the wall of the uterus. 

453. Displacements of the Appendages. — Displacements of 
the ovaries and tubes are very common with backward uterine 
displacement. Inflammatory troubles in the tubes cause them 
to drop down, from increased weight, and they are found behind 
the uterus in Douglas' pouch (Fig. 420). Frequently both tubes 



DEVIATIONS OF THE PELVIC ORGANS. 513 

may be situated in this position, and. united at their abdominal 
ends, form a single tumor, which contains pus or serum. The 
tubes are dislocated by their attachment to growths; ovarian, 




Fig. 416. — The Use of the Air Pessary to Reduce an Inversion- 




Fig. 417. — Reduction of Inversion with White's Apparatus. 

fibroid, or broad ligament cysts may draw the tube up into the 
abdominal cavitv and almost double its length. The most fre- 
33 



514 



GYNECOLOGY. 



quent dislocation of the ovaries is downward, into Douglas' 
culdesac. This prolapse can occur as a consequence of retro- 
displacement, or, independent of it, from elongation or rupture 
of the infundibulopelvic ligament. The dislocation can be 
occasioned by enlargement of the ovary, or the hypertrophy 
may be secondary to the displacement. The complication of 
retrodisplacement with ovarian prolapse is a source of additional 
distress and annoyance to a patient, as the tender ovarian struc- 




Fig. 418. — Intraperitoneal Dilatation of the Uterus. 



tures are subject to pressure from the heavy uterus and from 
the passage over them of the contents of the bowel. In this 
situation they are also subject to pain and distress during the 
act of coition, often rendering it so painful that the act is dreaded 
by the patient. 

454. Symptoms. — Prolapse of the ovary is generally associ- 
ated with chronic inflammation, either as a primary or secondary 
condition. The symptoms from which the patients suffer are 



DEVIATIONS OF THE PELVIC ORGANS. 



515 



necessarily those which to some degree are occasioned by the 
chronic disorder. In addition to this fact, however, the patient 
suffers distress during fecal evacuation, during the act of coition, 
in walking, and on standing. The ache and distress are some- 
times so severe as to render the patient unable to assume or 
retain the upright position ; a condition of semi-invaHdism from 
the influence upon the nervous system is engendered similar to 




Fig. 419. — Incision of the Posterior Uterine AVall Preliminary to Reduction 

of an Inversion, 



that present in chronic ovarian inflammation. There are no 
symptoms characteristic of tubal displacement. 

455. Diagnosis. — Prolapse of the ovary, when freely movable, 
is readily determined by bimanual palpation. A mass can be 
felt posterior to the uterus in Douglas' pouch, which varies from 
the size of an almond to that of a small orange. These masses 
can be pushed up, and, as they arise in the pelvis, fall toward the 



516 



GYNECOLOGY 



side corresponding to the affected ovary, and drop backward as 
soon as the force is removed. When the ovary is enveloped with 
inflammatory exudate in the pelvis, it is more difficult to deter- 
mine its situation, and, in fact, it may not be discovered until 
after the abdominal cavity is opened. Tubal enlargement with 
adhesions can frequently be mapped out as extending around the 
side of the uterus on its posterior surface, and the organs are 
more or less fixed. 

456. Treatment. — In inflammatory conditions of the tube 
involving the ovaries the treatment is the same as that of the 
diseased condition, as described in Section 399. Prolapse of the 

ovary associated 
with chronic ovar- 
itis, in which the 
ovaries are very 
much enlarged, is 
best treated by ex- 
tirpation. When the 
enlargement is sim- 
ply due to prolapse, 
causing more or less 
ovarian edema, the 
organ should be 
brought up and 
fixed in its proper 
position. Frequent- 
ly shortening the 
round ligaments or 
ventrofixation will 
bring with it the 
restoration of the 
position of the ova- 
ries. When these, 
however, do not rest 
upon the posterior surface of the broad ligament, but drag 
backward into Douglas' pouch, the infundibulopelvic ligaments 
should be shortened or the external end of the ovary should be 
stitched to the posterior surface of the broad ligament near its 
upper part. Efforts have been made to maintain the ovary in 
its restored position by mechanical means, but in my experience 
they are usually ineffective. The ovary slips behind the pessary, 
though it have a thick bar, becomes pinched, and adds to the 
distress of the patient. Frequently the ovary will be caught 
behind the instrument, and the patient will be unable to move 
for a few minutes, owing to the severe pinching of the inflamed 
organ. 




Fig. 420. 



•Prolapsus of Ovary and Tube behind 
Uterus. 



GEXITO-URIXARY HEMORRHAGE. 51' 



GENITO-URINARY HEMORRHAGE AND ECTOPIC GES- 
TATION. 

457. Hemorrhage a Symptom. — The advisability of consid- 
ering hemorrhage under a separate heading or division when it 
must be recognized that under all circumstances its presence is 
an indication of the existence of disease rather than the actual 
palpable disorder may be questioned, but my experience has 
caused me to beheve that in the diseases of women the gravity of 
this symptom is not always fully appreciated, and that this 
failure will be better overcome if the subject is given the im- 
portance of a separate consideration. 

458. Site and Varieties. — Hemorrhage may arise from any 
portion of the genito-urinary tract and from the vessels within 
the adjacent cellular tissue. It can occur at any age. though 
it takes place but rarely, except from trauma, prior to puberty. 
The significance of hemorrhage is largely dependent upon the age 
at which it makes its appearance. The hemorrhage is called 
open when the blood escapes from the urethra, vagina, or through 
external injuries; concealed, when within the abdominal cavity 
or in the cellular tissue. In the latter, also, it may be denomi- 
nated as circumscribed. A discharge of blood mixed with urine 
is known SiS Jieuiatnna. An excess of bloody discharge syn- 
chronous with the regular menstrual period is named menor- 
rhagia; while bleeding of an irregular character is named metror- 
rhagia; a collection of blood in the cellular tissue is known as a 
hematoma; when in the tissues of the vulva or vagina it is called 
a vulvovaginal thrombus or hematoma; into the cellular tissue 
about the uterus, an extraperitoneal hematocele; an accumulation 
within the peritoneal cavity, which is encysted or closed in by 
peritoneal adhesions, is described as an intraperitoneal hemato- 
cele; hemorrhage into the structure of the ovar^^ when small, is 
known as an ovarian apoplexy; and when large, or frequently 
repeated, so the ovarian stroma is practically destro^^ed, and 
the collection forms a blood C3^st, it is called an ovarian hema- 
toma. A collection of blood in one of the hollow organs is known, 
in the Fallopian tube, as a hematosalpinx; in the uterus as a 
hematometra; and in the vagina as a hematocolpos ; or when the 
collection is so large as to involve all, it is denominated a hemato- 
colpometrosalpinx. Further distinctions are retro -uterine, cir- 
cumuterine, and ante-uterine hematocele, according to the situa- 
tion of the blood collection — behind, about, or in front of the 
uterus. 

459. Hematuria and Its Causes. — Hematuria is blood mixed 
with the urine, and is engendered by urethral caruncle, polypi, 
vegetations, fissures Tthe latter situated about the internal 



518 GYNECOLOGY. 

meatus) , and malignant disease of the canal. It occurs in acute 
and chronic cystitis, associated with more or less vesical ulcera- 
tion; in the aggravation of the disorder occasioned by the pres- 
ence of vesical calculi; and malignant growths or villous pro- 
jections from the vesical mucous membrane are a prolific source 
for the occurrence of blood in the urine. It is often produced by 
injury, inflammation, or malignant disease of the ureters or 
kidneys. Stone in the pelvis of the kidney frequently causes 
bloody urine. Occasionally, blood appears in the urine as a 
result of constitutional conditions. So frequently is it associated 
with malarial infection as to give rise to the term malarial 
hematuria. 

460. Symptoms and Diagnosis. — The blood may be mixed 
with the urine, giving it a dark, smoky, often almost black 
appearance, or may precede or follow the act of micturition, as a 
few drops of free blood mixed with the urine or in the form of a 
small clot. The clots may be bright and recent, or darkened by 
longer retention within the urine. Unmixed blood comes from 
injury or disease of the urethra; frequently a few drops or a 
small clot will follow urination when caused by a fissure of the 
meatus. When the bleeding is occasioned by disease or injury 
of the bladder, the urine is not constantly bloody. An evacua- 
tion may be perfectly clear and the next be bloody. 

The cause of the symptom is ascertained by careful exami- 
nation. Disorders of the urethral orifice are recognized by in- 
spection of the canal, by palpation, and, if necessary, by inspec- 
tion through an endoscope or a urethral speculum. A fissure 
at the internal urethral orifice causes severe pain upon palpation 
of the urethra. 

Inflammation of the bladder — cystitis — is recognized by pain- 
ful and frequent micturition and attacks of profuse bleeding. 
The microscope reveals the cellular elements of the blood and 
degenerating epithelium in the urine. In growths or foreign 
bodies palpation discloses thickened walls, increased tenderness, 
and possibly the mobility of a foreign body or calculus. Micro- 
scopic investigation of the fluid evacuated is of great value. 
Not infrequently the bladder may be the seat of profuse bleeding, 
which becomes coagulated, and the clots interfere with the col- 
lection and evacuation of the urine. 

Disease of the ureter and pelvis of the kidney may produce 
bloody discharge. Irrigation of the bladder permits the char- 
acter of the urine from the kidney to be determined. Through 
the speculum the ureteric orifice will often be seen as a pouty, 
more or less abraded elevation, from which bloody urine is seen 
to issue. Catheterization of the ureter will determine the char- 
acter of the secretion in the respective kidneys, and the existence 



GEXITO-URIXARY HEMORRHAGE. 519 

of disease in one or both of the organs. Calculi in the renal 
pelvis are generally a source of pain in the region of the kidney. 
The pain is generally felt along the course of the ureter, not in- 
frequently over the distribution of the genitocrural nerve. 

461. Treatment. — The treatment of hemorrhage is the same 
as that of the condition producing it. Hemorrhage from the 
bladder and urethra must be recognized as of importance. 
Measures for its relief (Section 340) have been described. 

When trouble can not be discovered in the urethra and blad- 
der, the treatment should be directed to the disease in the pelvis 
of the kidney. Before proceeding to internal measures, constitu- 
tional conditions should be excluded. If necessary, the blood 
should be examined for the presence of the malarial Plasmodium. 
The determination of malaria should indicate the use of anti- 
malarial remedies. Bleeding may be arrested by the employ- 
ment of astringents — tannic and gallic acids, hydrastis, and 
hamamelis. Tyson advises ferri persulph., gr. -j— J-, as very 
effective. 

Continuation of bleeding associated with renal calculus should 
indicate operation for its removal. Operation will be conserva- 
tive, for the continuance of the disorder necessarily results in 
renal degeneration and destruction. 

462. Genital Hemorrhage or Bleeding. — This term is em- 
ployed to distinguish bleeding which makes its exit externally 
and can arise from any portion of the genital tract. Bleeding 
of slight character, — a few drops, — which will occasionally soil 
the clothing, will be a source of great anxiety to a nervous patient 
and should be considered an indication for a careful investiga- 
tion by her physician. Such bleeding may arise from irritation 
of the vulva, warty growths, scratching induced by pruritus, 
from caruncle of the urethra, papillary gro^^i:hs and granulations 
of the vestibule or vaginal mucous membrane, lacerations, abra- 
sions or erosions, or beginning malignant diseases of the vagina 
or cervix, inflammation of the endometrium, or changes incident 
to gestation or parturition. More severe bleeding or hemorrhage 
is induced by injuries of the vulva caused by falling and striking 
against a sharp object, or by kicks or blows; these injuries cause 
very severe hemorrhage when the bulb of the vestibule is in- 
jured. Hemorrhage is also incident to malignant disease of the 
labia or clitoris, severe injuries of the vagina, or extensive lacera- 
tions of the cervix. Interstitial endometritis, fibroid growths 
encroaching upon the uterine cavity, and epithelioma, carci- 
noma, and sarcoma of the uterus are frequent causes. Hemor- 
rhage from the genital tract may also result from disease outside 
of the canal which interferes with its circulation; as inflamma- 
tory exudate, cellulitis compressing the vessels of the pelvis and 



520 GYNECOLOGY. 

interfering with the return circulation, displacements, extra- 
uterine pregnancy, intraligamentary tumors of the ovary or of 
the uterus, inflammation of the Fallopian tubes, chronic inflam- 
mation of the ovaries, and constitutional conditions which affect 
the circulation in the uterus (as, disease of the heart, of the 
kidneys, or of the liver). The circulation is very often tem- 
porarily influenced by the development of zymotic diseases. 
Severe uterine hemorrhage may occasionally usher in an attack 
of typhoid fever. Disturbance of the process of gestation by 
hemorrhage may indicate the occurrence of abortion or of pre- 
mature labor, or may follow abortion or labor where the secun- 
dines or portions of the placenta are retained. 

463. Diagnosis. — The determination of the existence of 
hemorrhage, of course, presents no difficulty. It is exceedingly 
important, however, that we should be able to recognize its 
etiology and source. This will often be found a difficult ques- 
tion. No physician does justice to his patient who permits her 
to bleed without subjecting her to a careful examination in 
order to ascertain the cause. Not infrequently patients will 
object to the necessary examination. Such a patient should be 
plainly given to understand that the physician can not continue 
to treat her unless she affords him an opportunity to know the 
existing conditions. He will do himself less injury by absolutely 
refusing to treat the case than he will if he yields to the patient's 
objection and endeavors to palliate an unrecognized disease. 
Unfortunately, many patients have an idea that hemorrhage 
at or near the climacteric is a condition to be expected, so if free 
bleeding occurs at this period, they attribute it to the coming 
change of life and continue to endure it. Members of the medical 
profession, I find, are often responsible for this misconception, 
for frequently they advise the patient that the bleeding is inci- 
dent to her period of life, and that, therefore, when this has 
passed over, the hemorrhage will cease. Such a statement, 
however, only calms the patient and favors a transition from the 
existing to another and perhaps more serious state. Moreover, 
when the discovery of the actual condition is made, the time for 
radical measures has elapsed. The occurrence of hemorrhage 
incident to local or constitutional conditions makes it incumbent 
upon us to interrogate carefully every organ of the body to be 
certain of its cause. In every woman who suffers from hemor- 
rhage, where we are able to eliminate constitutional conditions, 
and where we can discover no disorders in the tissues about the 
organ or any disease of the cervix to explain the cause, the 
uterine cavity should be thoroughly explored. The previous 
history of the patient will enable us to ascertain whether the 
bleeding is due to the retention of products of a recent gestation. 



GENITO-URINARY HEMORRHAGE. 521 

Bimanual examination will generally reveal even small growths. 
Such a condition will be manifested by localized areas of enlarge- 
ment or resistance in the organ. Some of these growths, being 
pedunculated, can be moved about in the uterine cavity to a 
limited degree. Combined palpation also affords information 
as to the possibility of malignant disease. The latter occurs 
more frequently in the cervix, and when it exists in the body, it 
causes more or less hardening and sense of resistance from the 
presence of infiltration. This, of course, depends somewhat 
upon the associated reactionary inflammation. If the disease 
involves only a portion of the lining membrane of the uterus 
without the infiltration extending into the wall, the bimanual 
examination will not reveal the induration. Therefore it will 
be necessary to explore the uterine cavity, preferably with the 
finger. The finger within the uterus and the hand over the 
abdomen enables one to outline and definitely determine the 
thickness and rigidity of the wall and the extent of induration 
as well as the general condition of the uterine mucous membrane. 
In the nonpuerperal uterus, however, one can not readily em- 
ploy digital exploration of its cavity without a previous dilata- 
tion. Dilatation may be accomplished by a variety of methods, 
one of which is the employment of mechanical dilators or of 
graduated bougies. This procedure affords an excellent oppor- 
tunity for the employment of therapeutic measures within the 
uterus, but sufficient dilatation of the organ can not thus be 
secured to allow the introduction of the finger without tearing 
and inflicting serious injury to the structure of the cervix. The 
cervix may be split on either side of the internal os with scissors 
or knife, after which the canal can be dilated or stretched enough 
to permit the introduction of the finger. Often this method of 
procedure is associated with an extensive laceration of the uterine 
structure, and, furthermore, incision of the cervix is too radical 
an operation for mere exploration. It is only when it is neces- 
sary to institute treatment of a threatening condition within the 
uterine cavity that we would advise cervical incision. Another 
method of dilatation is that devised by Vulliet, which consists 
in packing the uterine cavity with pieces of gauze until the cervix 
becomes gradually dilated, and renewing this gauze packing 
until the uterine cavity is so well dilated that the finger can be 
readily introduced. This plan is open to the objections, how- 
ever, that the gauze is an irritant, requires care that the patient 
does not become infected during the progress of the procedure, 
and in many cases, particularly when the cervix is the seat of 
inflammation and is a little rigid, the dilatation is ineffectually 
accomplished. 

The most effective method of dilating the cervix is accom- 



522 GYNECOLOGY. 

plished by the use of tents. The tents may consist of sponge, 
laminaria, or tupelo. Sponge tents are objectionable on account 
of the difficulty of rendering them sterile and because of the fact 
that they readily become impregnated with the discharges, 
which quickly decompose and predispose to infection. This 
danger has in some degree been obviated by the suggestion that 
the tent be covered with a rubber sleeve, but this requires the 
employment of special measures to convey the moisture to the 
tent. The laminaria tents are exceedingly effective, preferably 
those which are perforated. The tent should be carried into 
the uterine cavity without much force, the tent and the canal 
having been previously rendered as far as possible sterile. As 
large a tent as can be introduced should be employed. When 
the cavity is somewhat dilated or when the first tent is not 
sufficiently large, and we wish for more complete dilatation, a 
number of tents or a nest can be employed. More rapid dilata- 
tion is accomplished by previously moderately stretching the 
canal with bougies. If aseptic precautions are observed, the 
danger is not thereby increased. The details of the procedure 
and the precautions to be exercised have been given. (Section 

77-) 

464. Treatment. — The treatment should be directed to the 
disorder which has caused the hemorrhage. We may not, how- 
ever, be ready, or the patient can not be subjected to radical 
treatment, while the hemorrhage is so severe as to necessitate the 
exercise of measures to save her life. Various remedies are 
advocated for relief of hemorrhage — agents which exercise con- 
tractile power upon the involuntary uterine mucous membrane, 
of which ergot is one of the most efficient. It not only causes 
contraction of the uterine muscle-wall, but also decreases the 
amount of blood that is sent into the uterus through the con- 
traction of the uterine vessels. Thyroid extract and the extract 
of mammary gland have been highly extolled. The various 
astringents are of benefit, as gallic and tannic acids ; dilute sul- 
phuric acid; iron salts, especially the persulphate of iron; ham- 
amelis; hydrastis and its salts, hydrastin and hydrastinin; and 
the tincture of cinnamon. The latter may be given with good 
effect in combination with either gallic or tannic acid, giving 
from ten to thirty grains of the acid with a tablespoonful of the 
liquid. The patient should be kept perfectly quiet in bed ; if 
hemorrhage is severe, she should be interdicted from rising even 
to evacuate the bowels or to void the urine. Cold applications 
may be made to the abdomen, and heat or a mustard plaster ap- 
plied between the shoulders, in order to divert the current of blood 
from the pelvis. Local applications of various astringents, such 
as alum, zinc sulphate, hydrastis, or hamamelis, used in strong 



GENITO-URINARY HEMORRHAGE. 523 

solution or as a douche, may be employed. Douches of hot 
water should be given the patient while in the recumbent posi- 
tion, using water at from iio° to 115° F., even 120° F. if the 
patient can bear it. xYpplications to the uterine canal by in- 
jecting a few drops of perchlorid of iron may be employed, or the 
cavity may be swabbed with it. The objection to the injection 
is that the uterine cavity will contract upon its contents, causing 
contraction of the cervix, by which the contents are forced from 
the uterine cavity into the tubes, and produce inflammation 
within them, or, worse, a localized peritonitis. Gersterberg 
employs a strong solution of formol upon a cotton-wrapped 
applicator. A solution of aluminium acetate has been advo- 
cated. When hemorrhage is severe, endangering the patient 
by its continuance, the uterine cavity should be tamponed, by 
packing a good-sized piece of gauze firmly into its cavity. This 
prevents the further discharge of blood and facilitates the dilata- 
tion of the canal until it can be explored. These measures for 
the treatment of hemorrhage are merely palliative. They do 
not correct the fault or the trouble which induced it; and the 
earlier radical treatment can be instituted, the better it is for 
the patient and the more readily is the condition controlled. 
Slight bleeding from the vulva and vagina is readily controlled 
by making applications of an astringent or a styptic, such as 
persulphate of iron, directly to the diseased surface. The cavity 
should be packed, in order to secure further improvement through 
pressure. When bleeding occurs from an injury to the vulva, 
the most efficient means is to enlarge the external injury and to 
secure the bleeding vessel by ligation. When a large surface 
bleeds, the hemorrhage is best controlled by packing with iodo- 
form gauze, making firm pressure upon or into the wound. 
Atmocausis, or the application of steam to the uterine cavity 
by a special apparatus, has had many advocates, but it would 
seem desirable to employ more controllable measures, for it is 
impossible to accurately regulate the amount of destruction to 
which the uterine mucosa will be subjected, and to definitely 
equalize its distribution. 

465. Vulvar Hematoma or Hematocele. — Vulvar hematoma 
or thrombus is a term applied to hemorrhage which takes place 
into the tissues of the vulva. It arises as a result of injury 
sufficient to cause rupture of a vessel without a break in the in- 
tegument. When the injury involves the bulb of the vestibule, 
the hemorrhage may be extensive, and cause a large-sized tumor, 
which involves one or the other large labium. It also occurs 
from rupture of varicose veins or from compression of vessels 
during the progress of labor. The latter is the most frequent 
cause. The tumor may attain the size of an orange or even of 



524 GYNECOLOGY. 

the fist, and may be very tense and painful. It usually occurs 
suddenly, and is associated with more or less burning and pain in 
the region of the swelling while it develops. When the skin is 
unbroken and the collection does not become infected, it may be 
completely absorbed. 

466. Vaginal Hematoma or Thrombus. — This condition, un- 
complicated, is of rare occurrence. It is usually associated with 
hemorrhage into the vulvar tissue, forming a vulvovaginal 
thrombus. It usually occurs upon one side of the vagina, and 
is most frequently a result of injuries sustained during labor. 
The exciting agent is the passage of the presenting part of the 
child, which frequently pulls off and stretches the vaginal at- 
tachments. This causes rupture of the vessels and severe 
bleeding. The tumor may attain a very large size, compress 
the vagina and rectum, and cause dif^culty in micturition. The 
physician may be in doubt, when called to see such a patient, 
whether it is an accumulation of blood or a suppurative process. 
The better plan of procedure is, of course, to make a careful 
examination. With the history of the patient in mind, we may 
be able to eliminate the probability of it being inflammatory, 
especially when it occurs shortly after a confinement. During 
the year 1898 I saw a patient, thirty-four years of age, three 
weeks after her first confinement, who had passed through a 
normal labor. She had, however, sustained a slight laceration 
of the perineum, which was repaired. Two weeks subsequent 
to her delivery she developed some elevation of temperature, 
with more or less distress in the pelvis, and examination dis- 
closed a large swelling which compressed the vagina and rectum. 
The mass thus formed was quite large; the right buttock was 
edematous and the mass protruded into the vagina to such a 
degree as greatly to obstruct it, as w^ell as to encroach upon the 
rectum. Sensation of fluctuation was indistinct. The right 
buttock was so much more prominent than the left and the sen- 
sation of elasticity, almost fluctuation, so marked that I decided 
to incise through it and thus reach the mass, rather than to make 
an incision from the vagina. The incision into the buttock, 
however, disclosed that the swelling in it was entirely edematous. 
Through this incision the levator ani muscle was opened, when 
there was at once a discharge of a large quantity of bloody fluid 
and clots. By pressure through the vagina, the mass was readily 
removed, and the patient looked and expressed herself as feeling 
greatly improved. A gauze wick was passed through the wound 
into this cavity with a view to insure drainage and to prevent 
its premature closing. The gauze was removed at the end of 
twenty-four hours, and the subsequent progress of the patient 
was uninterrupted. Another case of this kind came under my 



GENITO-URINARY HEMORRHAGE. 525 

observation in a young woman who had been delivered by 
forceps. The right side of the pelvis was apparently occupied 
by a large clot, which bulged into the vagina, protruded into 
the labium, and gave rise to suggillation of the entire buttock. 
This mass was incised from the vagina and it was found to extend 
up into the broad ligament of the right side. The clot was 
thoroughly turned out and the cavity packed with a large quan- 
tity of iodoform gauze. The patient recovered. I have ob- 
served one case of vaginal hematocele in which labor was com- 
plicated by an ovarian dermoid. The union of this growth with 
the uterus had been destroyed by previous torsion. The tumor 
subsequently became engrafted upon the omentum, from which, 
by a broad band of adhesion, it evidently received its nutrition. 
It was attached below by folds of the peritoneum, which ex- 
tended over and to the left of the bladder. In the latter fold, 
dipping down into the pelvis in front of the bladder and vagina 
and to the left of the latter, was an extensive collection of clotted 
blood, which had evidently been produced by pressure upon 
the inferior attachments of the tumor during the progress of 
labor. 

467. Diagnosis. — Vulvar hematoma is likely to be confounded 
with edema of the labium and with labial tumors. Its devel- 
opment, however, is too sudden for the latter condition. Edema 
of the labium is generally associated with other disorders. It is 
not one-sided. Both labia are involved unless the edema is due 
to some special cause, in which there is obstruction of vessels 
or lymphatics on one side only. Vulvar and vaginal thrombi 
are usually associated, producing the condition already de- 
scribed as vulvovaginal thrombus. The condition generally 
follows difficult or complicated labors. Pus collections are 
rarely found in the lateral walls of the vagina, but are most fre- 
quently pushed into the vagina from the posterior fornix. 
Thrombi, on the other hand, are frequently found upon the 
lateral surface and rarely affect the posterior vaginal wall. 

468. Treatment. — The amount of bleeding in these thrombi 
is usually limited, for the pressure of the tissues into which bleed- 
ing occurs naturally controls it. In noninfected cases the 
extra vasated mass is ultimately absorbed, although in large 
collections it may remain for quite a long time. A patient 
recently came under my observation in whom an operation 
was required for pelvic inflammation. On examination, a 
mass was felt posterior to the rectum, in the neighborhood of 
the sacrococcygeal articulation, which had an elastic sensation. 
Upon inquiry, I found she had undergone her flrst labor six 
months before, with a history of an injury to the coccyx. The 
coccygeal injury had, however, disappeared ; the mass remained. 



526 GYNECOLOGY. 

As I had already made an incision through the vagina into the 
peritoneal cavity, I did not care,' therefore, to attempt to open 
into this from the vagina, on account of the dissection required 
around the rectum. An incision was made into this sac pos- 
terior to the anus, when a teacupful of thick, pasty, reddish 
material, evidently the remnants of the clot, was evacuated. 
Gauze drainage was instituted, and the cavity gradually closed. 
When the collection is small, it may, without detriment to 
the patient, be left to nature; but when large, the pressure 
produces thinning of the enveloping wall and permits the ready 
introduction of infecting germs, either from the rectum or 
the vagina. In such collections the danger of subsequent 
infection is decreased by free incision and the evacuation of 
the accumulation. Not only should the clots be removed, 
but measures must be employed to preclude further hemorrhage. 
A large bleeding vessel may be secured by passing a ligature 
beneath or about it with a needle. When ligation is impractic- 
able, hemorrhage should be controlled by packing with iodoform 
gauze. The gauze should be retained for two or three days, 
and should be renewed with a smaller amount, in order to keep 
the external wound open long enough for the cavity to undergo 
thorough contraction. 

469. Peri-uterine hemorrhage may be intraperitoneal or 
extraperitoneal. Intraperitoneal hemorrhage, unless preceded 
by inflammatory adhesions which form limitations, is free, and 
may be large in quantity. Extraperitoneal hemorrhage takes 
place into the cellular tissue about the uterus and the broad 
ligaments, and is limited by the pressure of the tissue. Hemor- 
rhage into the cellular tissue beneath the peritoneum under- 
goes coagulation and forms a bloody tumor, known as a hemato- 
cele. It is analogous to the thrombus which occurs during 
the progress of labor, and which we have described under the 
term vulvovaginal. 

Hemorrhage into the peritoneal cavity will form a coagulum, 
and subsequently a tumor, or, when very free, may remain 
liquid and the hemorrhage continue until the death of the 
patient or until surgical intervention is practised. 

470. Causes. — The causes may be divided into two classes: 
first, hemorrhage that results from extra -uterine pregnancy, 
which is more important, because more frequent and more 
serious in its results; second, hemorrhage of nonpuerperal 
origin, which occurs without the existence of fecundation. 
The pelvis being the most dependent portion of the abdomen, 
hemorrhage from any of the intra-abdominal viscera, or within 
any| portion of the peritoneal cavity, naturally gravitates into 
the pelvis. Thus, we may have intra-abdominal hemorrhage 



GENITO-URINARY HEMORRHAGE. 



02 i 



from traumatic injuries of the liver or spleen, rupture of an 
aneurysm of the aorta or of the celiac axis, rupture of varicose 
veins, from the ovary, regurgitation from the Fallopian tube of 
menstrual blood (particularly when there is obstruction of the 
uterine neck), rupture of a uterine or tubal collection, rupture 
of bands of adhesion in the pelvic peritoneum, slipping of a 
ligature, or the retraction of a cut vessel following an opera- 
tion. Any of these causes may lead to an accumulation of 
blood in the pelvis or, particularly, in Douglas' pouch, whereby 
the intestines containing gas are floated up and the uterus is 
pushed forward. Soon or later the coagulated blood causes 
irritation and leads to the formation of adhesions, bv which 




Fie 



421. 



-Intraperitoneal Hemorrhage. 



the collection may become encysted and form what is known 
as an intraperitoneal hematocele (Fig. 421). The most fre- 
quent cause, however, belongs to the division of the puerperal 
or extra-uterine. 

471. Symptoms. — When hemorrhage is due to extra-uterine 
pregnancy, its occiu-rence is preceded by disordered menstrua- 
tion, and the patient will probably give a history of having 
missed one or more periods. The ordinary symptoms of preg- 
nancy have been present and she has supposed herself preg- 
nant. Pain of a severe, cutting character has been felt upon 
the affected side, which may have been paroxysmal and quite 
intense in character. However, it mav have occurred with- 



528 GYNECOLOGY. 

out any premonition as a violent attack of tearing, cutting 
pain, which caused the patient, while standing, to fall and 
become unconscious. These phenomena may have been followed 
by repeated attacks of syncope, in which the countenance 
became pale, anxious, and covered with clammy perspiration, 
the lips pale and blanched, respiration sighing, the sight ob- 
scured, a sensation of blindness being present, the mind fre- 
quently wandering, or the patient remains unconscious or 
passes from one attack of syncope into another. The pulse 
at the wrist becomes exceedingly feeble, faint or impercep- 
tible, the temperature subnormal, and all the indications of 
approaching dissolution are present. 

According to the intensity of the hemorrhage, the patient 
may either die in the first attack, — that is, within half an hour 
or an hour after the first symptoms, — or slightly rally and 
an apparent recurrence of the hemorrhage follow with death 
within less than twenty-four hours. Should the patient sur- 
vive twenty-four hours and rally, her strength may gradually 
return and recovery follow; or a secondary hemorrhage may 
occur and terminate fatally. In the early stage of the trouble 
no physical signs of the existence of hemorrhage can be recog- 
nized. Possibly a large quantity of blood exuded into the 
abdominal cavity of a thin woman could be recognized by the 
sensation of fluctuation. After twenty-four hours the blood 
will accumulate in the pelvis, and we can then recognize a sen- 
sation of fluctuation and slight resistance by vaginal palpation. 
Changing the position of such a patient will permit this col- 
lection to flow out of the pelvis and its presence be no longer 
recognized, when by again lowering the pelvis the accumu- 
lation returns. The coagulated blood causes more or less 
irritation, which results in the exudation of plastic material 
and the occurrence of a localized peritonitis. The abdomen 
becomes tender to the touch, and a febrile reaction occurs. 
The temperature, instead of being subnormal, now rises to 
ioi° F., often even to 103° F. The patient may suffer from 
distress due to the pressure of such a mass upon the rectum 
or against the uterus and bladder, causing frequent micturition 
or even incontinence. When the plastic peritonitis occurs, 
the patient will have nausea and abdominal distention. The 
peritonitis results in the accumulation becoming encysted 
in the pelvis and its watery portions partly absorbed. This 
gives rise to a more constant and resistant mass, which pushes 
the uterus upward and forward. The intestines are raised 
above it and a very good idea of the character of the trouble 
is afforded. The mass varies in its consistency; sometimes 
it is hard, at others soft, or the same mass may have several 



GENITO-URINARY HEMORRHAGE. 529 

points of softening. The uterus may be enveloped by the 
tumor, producing what is known as a circumuterine hemato- 
cele. The action of the rectum and bladder may be greatly 
obstructed by compression of the mass against these organs, 
w^hich occasionally may cause symptoms of intestinal strangu- 
lation and retention of urine. Pressure upon the nerves often 
produces severe neuralgia of the lower extremities. Even 
should suppuration not occur, irregular attacks of fever are 
frequently the result of peritoneal reaction. The course of 
such a disease is essentially chronic or repeated attacks may 
follow each other. The congestion which takes place at the 
menstrual periods may result in acute symptoms. Suppurative 
inflammation in such a mass is ushered in by an aggravation 
of both the local and general symptoms, by chills, elevation 
of temperature, and profuse sweats. The tumor increases 
in size and undergoes softening. The mass may subsequently 
perforate into the rectum and cause the evacuation of dark, 
purulent, exceedingly offensive material in the stools, which 
may also produce more or less irritation of the rectum. These 
discharges are followed by a cessation or disappearance of the 
tumor. Perforation into the vagina or bladder may also occur, 
although it is more rare. Perforation into the abdominal 
cavity is fortunately very rare. When it occurs, however, 
a violent attack of general peritonitis follows. 

472. Extraperitoneal Hematocele. — Extraperitoneal hemor- 
rhage resulting in the formation of a hematocele may be pro- 
duced by puerperal or nonpuerperal causes (Fig. 422). The 
former, associated with ectopic gestation, are the more fre- 
quent. The nonpuerperal causes are the rupture into the 
broad ligament of varicose veins, and injury of an artery or 
its retraction from the stump when the pedicle is ligated en 
masse. 

473. Symptoms. — Extraperitoneal hematocele in the broad 
ligament is limited in its character, and causes symptoms similar 
to those which have already been enumerated for the intra- 
peritoneal variety, though in a much slighter degree. The 
indications of shock and collapse are much less marked, and 
hemorrhage, from its limitation, is much less serious in its 
influence. As it occupies the broad ligament, it is usually 
situated upon one side of the pelvis, and pushes the uterus 
to the opposite side. This hemorrhage may be situated either 
in the upper part or in the base of the broad ligament, and 
may produce different physical signs according to its situation. 
The hemorrhage, when low in the broad ligament, may dis- 
sect forward between the uterus and bladder, or back^^ard 
around the uterus beneath the peritoneum, and extend to 

34 



530 



GYNECOLOGY 



the Opposite side. In the great majority of cases, however, 
extraperitoneal hemorrhage is one-sided. 

474. Diagnosis. — Peri-nterine hemorrhage, whether intra- 
peritoneal or extraperitoneal, is determined by the phenom- 
ena of internal hemorrhage. It is true that similar symp- 
toms — a sharp pain, symptoms of collapse — might arise from 
rupture of a pyosalpinx or a pelvic abscess. In such accidents, 
however, acute agonizing pain is caused, with symptoms of 
peritoneal reaction which are more intense than when from 
the hematocele, but a tumor does not form. A retrofiexed 
gravid uterus may be mistaken for hematocele, but the out- 
line of the bounda- 
ries of the organ are 
more definite than 
those found in hem- 
atocele. In the 
latter the uterus is 
frequently inclosed 
within a mass or 
pushed forward, 
while by a careful 
examination in a 
retrofiexed gravid 
uterus the cervix is 
found at a higher 
level, either in the 
axis of the vagina 
or looking forward ; 
a distinct angle ex- 
ists between it and 
the smooth, defi- 
nitely outlined mass 
filling up the pelvis, 
which should not 
be confounded with 
hematocele. Ovarian cysts and uterine fibroids imprisoned 
within the pelvis possess nothing in common with hematocele. 
The manner of appearance and the course of development of 
the condition are entirely different. Extra-uterine pregnancy 
before rupture does not present similar symptoms, although it 
may be a starting-point for the later hemorrhage, and unless 
the examination is carefully performed, rupture may result from 
the methods used for diagnosis. Extraperitoneal hemorrhage is 
determined from intraperitoneal by the situation of the collec- 
tion upon one side, which is more definitely localized, its boun- 
daries more sharply defined, and the uterus generally pushed to 




Fig. 422. — Extraperitoneal Hematoma. 



GENITO-URINARY HEMORRHAGE. 531 

the Opposite side, while in the intraperitoneal hematocele the lat- 
ter is surrounded by the accumulation or is pushed forward. 
The determination of the cause of the hemorrhage is not always 
easily accomplished. Previous symptoms of pregnancy, amenor- 
rhea, with symptoms rapidly ushered in, profound depression, 
and very marked anemia, should lead to the suspicion of probable 
rupture of a fetal sac. Symptoms of collapse, or depression, of 
internal hemorrhage, may arise from rupture of internal varicose 
veins. In hemorrhagic salpingitis the condition is more insidi- 
ous, the progress more slight, owing to the gradual effusion of 
blood. Should there be any doubt of intraperitoneal hemor- 
rhage, the true condition can be surely determined by making 
an exploratory puncture through the posterior vaginal fornix. 
This is a justifiable and commendable procedure. 

475. Prognosis. — The affection is always a serious one. 
We can not be certain that death may not suddenly result 
from a continuation of the hemorrhage, or, when hemorrhage 
has apparently been arrested, that the clot may not be loosened 
and hemorrhage again recur. In large collections the progress 
of the case is exceedingly tedious. Plastic material remains 
about the uterus for a long time, becomes more or less organized, 
is frequently a source of discomfort, and often a cause of sterility. 
That sterility is not invariably caused is evident from the num- 
erous cases recorded in which women have suffered from hemato- 
cele, in whom the collection is ultimately absorbed, and the 
patient again undergoes an ectopic gestation, and the experience 
is repeated. The presence of a large collection of blood within 
the pelvis is a source of continuous danger, from its close prox- 
imity to the vagina and rectum, through either of which chan- 
nels infectious material may enter, to cause pelvic suppuration. 
Suppuration is particularly likely to occur if the individual has 
had previous tubal disease, from which, doubtless, the infection 
develops. The extraperitoneal variety is less serious in its in- 
fluence, much more likel}^ to undergo absorption, and leaves 
less evidence of its previous existence. Its situation renders 
it less susceptible to infective changes. When the collection 
is large, however, and has existed for some time, the patient 
will, without question, have a more favorable prognosis by 
the exercise of measures for its removal. 

476. Treatment. — iVctive interference must depend very 
much upon the character of the symptoms and the severity 
of the attack. When the symptoms are such as to indicate 
extra-uterine pregnancy, with rupture of the sac and escape 
of a large quantity of blood into the pelvis, the abdomen should 
be opened promptly, clots removed, and the bleeding vessel 
secured. In profuse internal hemorrhage ligation of the bleed- 



532 GYNECOLOGY. 

ing vessel is just as certainly indicated as in hemorrhage from 
the radial or femoral artery. When hemorrhage has apparently 
been arrested and a reactive peritonitis develops, we are not 
absolutely certain that the clot can not be displaced and the 
patient suffer from a recurrence of hemorrhage, which may 
be fatal, or that the collection of fluid about which nature is 
forming its barriers may not become infected from the neigh- 
boring, hollow viscera and cause subsequent changes, necessitat- 
ing its evacuation, with increased danger to the patient. In 
extraperitoneal hemorrhage the indications for operation are 
not so marked. The symptoms are much slighter, the amount 
of exudation is less, and the probabilities of infection are dim- 
inished. In such cases we can afford to wait and trust to nature 
to absorb the effused fluid. In large collections, however, 
much time will be saved by its evacuation. The method of 
operative procedure will depend upon the time the condition 
comes under observation. In an acute attack, and with an 
evidently bleeding vessel, we should follow the procedure which 
affords the most accurate and complete exposure, with the 
most ready access to the field of hemorrhage. Abdominal 
incision meets every indication, as through it we are enabled 
to see and to reach the bleeding vessel. When the patient, 
however, comes under observation a week or more subsequent 
to the hemorrhage, when the peritoneal reactive processes have 
resulted in the blood becoming encysted, and vaginal and 
abdominal palpation disclose that barriers have been formed 
by plastic exudate between the knuckles of intestine over the 
surface of the hematocele, the vaginal incision is the preferable 
procedure. This procedure is preferable for the reason that 
it respects the barriers which nature has constructed to limit 
the collection, and afTords a free opportunity for the evacuation 
of the clots. They are removed by the finger and by irrigation. 
With gauze packing and a free vaginal incision the subsequent 
progress of the case is much less severe and the length of the 
convalescence is decreased. When blood has been effused 
into the peritoneal cavity, and clots have formed, by neither 
the abdominal nor the vaginal method would we be able to 
remove all the clotted blood. The clotted material remains 
adherent to the sides of the sac and pelvis, and is likely in either 
procedure to cause a certain elevation of temperature as a result 
of the fermentation taking place in the retained fibrin. When 
the condition has gone on to suppuration, there should be no 
question as to the preferable procedure of reaching the collec- 
tion, when accessible, through the vagina, rather than by the 
abdominal route. It should be remembered that not all cases 
of internal hemorrhage are necessarily fatal nor require opera- 



ECTOPIC GESTATION. 533 

tive procedure. If the patient is unwilling to undergo an 
operation, or the conditions do not urgently demand it, the 
promotion of absorption should be accomplished by keeping 
the patient absolutely at rest in bed, by the use of the catheter 
to empty the bladder, and by the evacuation of the bowels 
or intestines by enemata. Absolutely interdict the use of 
opium, keep the vagina antiseptic by repeated douches, and 
when it is supposed that hemorrhage still continues, or that 
it is in danger of being renewed, apply an ice-bag over the 
abdomen, introduce ice suppositories into the rectum, and thus 
bring the ice in close contact with the bleeding vessels. In 
extraperitoneal hemorrhage indications for operation are much 
less marked. The absorption may be promoted by keeping 
the bowels regular and the patient at rest, and by the applica- 
tion of cold over the abdomen or of counterirritants. When 
operative interference seems indicated, the preferable procedure 
would be to make an incision through the vagina into the broad 
ligament, tear with the finger or a blunt instrument through 
the tissue of the ligament until the hematocele is reached, then 
enlarge the opening, turn out the clots, irrigate the cavity, 
and introduce gauze to afford vent for further discharge. When 
the collection is very large, it may sometimes be reached by 
an incision above Poupart's ligament to the peritoneum. The 
latter is then pushed off and the collection exposed, opened, 
and evacuated. After the cavity is thoroughly emptied, it 
should be packed with gauze, as already advised. 

477. Extra-uterine Pregnancy. — By extra-uterine pregnancy 
or ectopic gestation is understood the development of the ovum 
outside its normal situation within the uterine cavity. Much 
difference of opinion exists as to the point at which the union 
of the spermatozoon and the ovum, and its consequent fecun- 
dation, takes place. Tait very firmly asserted that in the 
normal condition this fecundation always occurred in the uterus. 
Others as emphatically believe that fecundation may occur 
at any point between the internal os and the exit of the ovum 
from the Graafian follicle. The recognition of the fact that 
in the lower animals the spermatozoa in normal conditions 
are found in contact with the ovary would seem to afford jus- 
tification for the belief that fecundation does not absolutely 
occur within the uterine cavity. Fecundation in the majority 
of cases undoubtedly occurs in the tube, and the changes which 
follow, as a result of fecundation, produce alterations in the 
uterine mucous membrane as a preparation for the reception 
of the fecundated ovum. 

478. Causes. — Much difference of opinion still exists as to 
the causes which lead to the occurrence of a misplaced ges- 



534 GYNECOLOGY. 

tation. Some would deny that inflammation has any part in 
its production, and would lead us to believe that the existence 
of inflammation in the tube always produces alterations which 
preclude the subsequent occurrence of pregnancy. Every 
abdominal surgeon of any experience, however, has seen cases 
in which well-marked tubal disease, and frequently of evident 
gonorrheal origin, have subsequently recovered, and the pa- 
tients have given birth to children. During the active inflam- 
mation of such tubes the abdominal orifices are closed off by 
exudate, which, during the following resolution, may be reab- 
sorbed and afford an entrance to the tube. Those who exclude 
inflammatory conditions as a cause attribute the occurrence 
of ectopic gestation to congenital conditions. These consist 
of long tortuous tubes containing numerous tubal constric- 
tions, and, especially, a tubal diverticulum. It is also attributed 
to intratubular growths, which limit the caliber of the canal, 
or to growths in the tubal wall, or to pressure of growths ex- 
ternal to the tube. The hypothesis of the migration of the ovum 
from the ovary of one side to the tube of the opposite side 
has been well established. As evidence, a history is recorded 
in which an intrauterine pregnancy occurred in a woman who 
had lost the tube of one side and the ovary of the opposite 
side. It has been supposed that the ovum, having become 
fecundated upon its emergence from the Graafian follicle, attains 
too great a size before it reaches the tube of the opposite side 
to permit of its passage down that canal. The vegetations 
upon the ovum, however, which form the chorion, do not develop 
until the ovum has come in contact with the tubal mucous 
membrane, hence this cause is of doubtful application. Every 
one cognizant of poultry is aware that occasionally an unusually 
large egg will be laid. Indeed, I have seen cases in which the 
egg was too large to pass through the canal. It is not improb- 
able that similar conditions exist in the formation of the ovum, 
and that, occasionally, an oversized fecundated ovum may 
lodge on its way to the uterus. Fright and emotional conditions 
at the time of conception are ascribed as causes. Were the 
latter, however, an important factor, we should be likely to 
find tubal gestation much more frequent in illegitimate cases. 
The study of the history of ectopic gestation long ago led 
to the recognition that a misplaced gestation was frequently 
associated with prolonged sterility. It is not unreasonable 
to believe that a period of sterility has been one in which in- 
flammatory conditions have existed and which have subsequently 
improved. Investigations of inflammatory conditions disclose 
the fact that loss of the tubal epithelium is of rather rare occur- 
rence. The existence of the gestation is due, not so much to 



ECTOPIC GESTATION. 



535 



the presence of patches of desquamated epithehum, as to in- 
flammatory changes which cause the canal to become narrowed, 
the folds of the mucous membrane thickened, thus rendering 
the passage of the fecundated ovum more tedious than under 
normal conditions. The expedition of the ovum to the uterus- 
is also retarded by the decreased peristalsis resulting from 
hyperplasia and loss of activity in the rauscular wall. Gon- 
orrheal inflammation seems to have a special influence in the 
production of ectopic gestation. Thus, Prochownik found 
gonorrhea in three out of eight cases, and Ahlfeld, in the few 
cases he has observed, also attributes the condition to gonor- 
rheal infection. Ectopic gestation may occur at any period 
of the reproductive life, as in a first pregnancy or in women 
who have borne a number of children. Analysis of a large 
number of cases will show that several years of previous sterility 
will occur in the majority of cases. It may occur in the first 
pregnancy of a 
woman who has been 
married eight, ten, 
or twenty years, in a 
woman who has not 
given birth to a child 
for five or six years ; 
or, again, it may fol- 
low immediately af- 
ter a labor or abor- 
tion. Furthermore, 
it may occur in the 
newly -made bride or 
in the unmarried. 

Both tubes may be pregnant concurrently or one tube may 
contain a tubal pregnancy or a tubal may complicate a uterine 
pregnancy. Cases have iDcen reported in which there occurred 
a twin pregnancy in the outer portion of the tube, and an inter- 
stitial or single pregnancy in the uterine end, making three em- 
bryos in the one tube. Dr. Krusen has reported a tubal preg- 
nancy which had ruptured, and in the sac three fetuses were 
found. 

479. Varieties. — Ectopic gestation is most frequently found 
to be of the tubal variety. Rare cases of ovarian pregnancy 
have been described, but when we consider the fecundated 
ovum and the conditions necessary for its nutrition and develop- 
ment, it still remains a question whether the ovum ever develops 
when not in contact with the Miillerian mucous membrane. 
It is quite probable that the cases described as ovarian preg- 
nancy have been originally tubo-ovarian and have become 




Fig. 423. — Tubal Pregnancy. 



536 



GYNECOLOGY. 



separated from their tubal relation. Tubal gestation occurs 
most frequently in the central portion of the tube (Fig. 423). 
It may be situated toward its abdominal end, and as it de- 
velops, is extruded or partly extruded and comes in contact with 
the ovary, when it is known as tubo-ovarian pregnancy (Fig. 
424). When situated within the central portion of the tube 




Fig. 424. — Tubo-ovarian Pregnancy. 

or ampulla, it is known as ampullar or tubal pregnancy. To- 
ward the uterine end, or that portion which passes through 
the uterine wall, it is known as tubo-uterine or interstitial 
pregnancy^ (Fig. 425). Rupture of a tube with partial escape 
of the ovum, which retains its placental attachment, may sub- 
sequently develop, when it becomes an abdominal pregnancy. 
Abdominal pregnancy, therefore, is secondary and not primary. 




f 



^^-' 



Fig. 425. — Tubo-uterine or Interstitial Pregnancy. 



The reimplantation of the ovum upon the peritoneal surface 
and its subsequent development have been asserted to be an 
impossibility, but when we find the tube having no longer any 
relation or connection with the sac, the placenta situated, as 
in the case of Tuholske, upon the liver, and apparently upon 
the folds above it, it seems impossible to explain its occurrence 
upon any other ground than that of reimplantation. 



ECTOPIC GESTATION. 537 

480. Course and Progress. — The fecundated ovum lodged 
in the tube finds a condition different from that of the ovum 
within the uterine cavity. In the latter, the mucous membrane 
consists of glandular or lymphoid tissue, which becomes thickened 
as a preparation for the reception of the fecundated ovum, in 
which the trophoblast cells of the ovum enable it to sink in 
and become embedded. The syncytial cells in the chorion 
arise from the trophoblast cells, and the uterine epithelium 
in no sense plays any part in their production. In the tube it 
meets with an entirely different condition. There are no glands, 
and there is much difference of opinion as to the formation 
of the decidua. This, in the uterus, consists of a compact and 
spongy layer, but in the tube, of a compact layer only. The 
decidua cells are found not so much in immediate contact with 
the wall of the tube as at either end of the sac. Bandler, in his 
investigations on the development of ectopic gestation, divides 




Fig. 426. — Tubal Abortion, 

it into three types: (i) The columnar type of tubal gestation; 
(2) the intercolumnar ; and (3) the centrifugal, (i) In the 
columnar variety, at no point in the tube wall or in the mucosa 
is there any decidual change or any condition representing the 
trophoblast cells or villi, consequently no decidua or tropho- 
spongia develops. The ovum is surrounded by mucous folds 
and only an invasion of the tubal capillaries follows. Abor- 
tion in these cases is easy and causes but little danger ; bleeding 
occurs; the fetus dies, and further hemorrhage expels it. The 
tube may subsequently become normal or a hematosalpinx 
may follow (Fig. 426). (2) In the intercolumnar type one- 
half of the tube is normal, the other torn and infiltrated, the 
mucous folds are involved down to the muscularis. The ovum 
is situated upon the tube wall, where it compresses and destroys 
the folds at the situation known as the serotina. These folds 
are united at either side about the ovum, forming a pseudo- 



538 GYNECOLOGY. 

reflexa. Some distance on either side of the serotina, tissue, 
resembHng decidua with closely grouped cells without capil- 
laries or spaces, rests upon and invades the free surfaces. The 
invasion traverses the mucosa in irregular branches or pro- 
jections about the blood-vessels, invading and infiltrating 
their muscular walls up to and into the lumen. Trophoblast 
cells are accompanied by syncytium, but at no point do the 
connective-tissue cells, the tubal folds, or the delicate sub- 
mucosa, if present, exhibit any evidence of change which re- 
sembles in the slightest degree those occurring in the uterine 
mucosa, from which the decidual cells develop. Neither is there 
at any point any change of a so-called syncytial character. 
The ovum rests upon the wall and the tubal fold immediately 
beneath it will be compressed, but the epithelium may remain 
in the depressions. Other folds may form a capsularis, which 
consists of mucosa alone. An intervillous space may develop 
when the capsularis is formed. The villi at the placental site 
enter the wall, and hemorrhage follows, especially upon the 
invasion of vessels of the capsularis by fetal cells. The preg- 
nancy may terminate in abortion, complete or incomplete, 
the latter usually being the rule. If the abdominal end is 
closed, a hematosalpinx or tubal mole may follow. (3) The 
syncytial type. In this the tissue of the tube is invaded by 
villi cell groups — syncytial cells. Here again there is no evi- 
dence of a decidua or of any decidual reaction. When unin- 
terrupted, the capsularis unites with the mucosa of the envelop- 
ing tube wall in the same way that this process is exemplified 
in the uterus. The centrifugal ovum sinks into the wall of 
the tube, when invasion of the wall and vessels by the villi 
occurs. Rupture may take place at the summit or hemorrhage 
from invasion of the vessels entering into the intervillous spaces. 
Bleeding from the villi penetrates the serosa and rupture at 
the placental site may follow, or we may have multiple per- 
foration and erosions. The ovum apparently eats up the tube 
wall and its destruction is not the result of pressure. In such 
cases the perforations may be so minute as only to be revealed 
by a microscope. The death of the ovum may not arrest the 
growth of the villi. This form furnishes the majority of cases 
of rupture. Very frequently the hemorrhage is due not to 
rupture, but to the erosions from the perforating villi. The 
presence within the tube of the developing ovum causes the entire 
structure to become turgid and vascular. There is some tendency 
in the tube to the development and extension of its structure, 
but to a much less degree than in the uterus. The wall becomes 
stretched, attenuated, and thin. The mucous membrane is 
stretched and its folds effaced. As the tubes vary in length 



ECTOPIC GESTATION. 539 

and thickness, the rapidity of thinning correspondingly differs. 
When the ovum is situated in the outer third, changes follow 
in the ostium. In the first four cases the fimbria are swollen, 
turgid, and the congestion extends to the adjacent muscular 
and serous tissue; the fimbria are gradually retracted, while 
the peritoneal margin of the ostium forms an irregular ring, 
which in four and one-half weeks projects beyond the ends 
of the fimbria. It finally contracts, and at the end of the eighth 
w^eek is completely contracted and hermetically sealed. The 
occlusion, however, is not constant. Occasionally the ostium 
dilates. The nearer the ovum is situated to the abdominal 
end, the less likely will it become closed. As the tube distends, 
its vessels rupture and hemorrhage takes place, which fills 
up the sac and may cause the extrusion of the ovum. The 
more firmly the tubal end becomes occluded, the greater the 
danger of tubal rupture. Its situation near the abdominal 
ostium favors its extrusion through the opening into the ab- 
domen as a tubal abortion. Moles occur in tubal as in uterine 
gestation; indeed, they are more frequent in the former. They 
vary from one to eight centimeters in diameter and are glob- 
ular or ovoid, assuming the latter shape in the larger varieties. 
The tubal moles are formed by hemorrhage, which occurs in the 
subchorionic diameter, between the chorion and the amnion. 
This hemorrhage may be gradual or sudden, and results in 
the death and often in the disappearance of the embryo. The 
puerperal origin of the condition in the absence of any vestige 
of the fetus is recognized by the discovery, with the micro- 
scope, of the chorionic villi. The outer investing membrane, 
the chorion, is generally shaggy, with villi, which are rendered 
more visible by washing the clot under a gentle stream of water. 
When the amniotic cavity is obliterated, doubt may exist 
as to the character of the mass, but section will disclose the 
villi in clusters as small circular bodies. Tubal abortion has 
been mentioned as one of the terminations of tubal gestation, 
when the developing embryo occupies the external third of 
the tube. The nearer the fecundated ovum is situated to the 
ostium, the greater the danger of its extrusion. As the em- 
bryonal sac increases to a size beyond that which the tube is 
able to accommodate, it is pushed out through the funnel- 
shaped cavity and escapes into the abdomen. This accident 
is denominated tubal abortion, and is frequently associated 
with profuse hemorrhage, which is very similar to that which 
occurs in uterine abortion. The mole is discharged with copious 
hemorrhage into the peritoneal cavity. This displacement is 
likely to take place during the first two months of the preg- 
nancy. When the ostium is closed, blood escapes from the tube 



540 GYNECOLOGY. 

only after rupture of the sac. The quantity of blood discharged 
is sometimes enormous and attended with all the symptoms 
of internal hemorrhage. This condition is one of the most 
frequent causes of pelvic hematocele. Internal hemorrhage 
in such cases has been ascribed to metrorrhagia, to reflex men- 
strual discharge from the uterus, or to hemorrhage from the 
Fallopian tube. The reason why it has been associated with 
metrorrhagia is that while the embryo is developing in the tube 
a decidua is forming in the uterus. With a tubal abortion, 
hemorrhage occurs from the uterus as a result of the separation 
and the expulsion of this decidua. This not infrequently 
happens near the time the patient expects to menstruate, and 
is, consequently, regarded as reflex menstrual fluid. Very 
frequently the bloody discharge from the uterus may be derived 
from a gravid tube in protracted tubal abortion. If the bleed- 
ing occurs at a time not synchronous with the menstual flow, 
it is often attributed to a disorder of the uterus. In all such 
cases the affected tube and the bloody discharge should be 
carefully examined for the presence of the embryo or the chor- 
ionic villi. The abortion may be complete or incomplete — 
complete when the embryo and its envelope are discharged; 
incomplete when a portion remains attached to the tube. The 
latter is the more common. The danger is increased in these 
cases, owing to the fact that the bleeding is apt to recur while 
the mole is retained. The villi will be disclosed by careful 
microscopic examination of the extruded mass and are dis- 
covered in sections of the adherent pole of the mass. 

A third termination of tubal gestation is that of rupture. 
As the embryo develops, the tube becomes more and more 
thinned, until it is no longer able to resist the inward pressure, 
and rupture results. Rupture of the gestation sac may be 
considered under: first, primary rupture; second, secondary 
rupture — each of which may be intraperitoneal or extraperi- 
toneal. Primary rupture takes place at any time between 
the third and tenth weeks after impregnation, and is rarely 
deferred beyond the twelfth. Predisposing causes of rupture 
are the gradual thinning of the gestation sac by the growth 
of the ovum or the undue distention of the membrane by 
hemorrhage, especially at the seat of implantation of the chori- 
onic villi. The perforation of the tubal wall by the villi 
may be excited by violence, as jumping from a train, strain- 
ing at stool, jarring of a carriage, vomiting, or sexual congress. 
Rupture may occur as a result of efforts to determine the diag- 
nosis. 

It was my misfortune to see a case of this kind in which 
the examination by myself, and subsequently by the attending 



ECTOPIC GESTATION. 541 

physician, was followed within a few minutes by symptoms 
of profound collapse, which confirmed the suspicion that an 
extra-uterine pregnancy w^as present. As soon as permission 
could be secured the abdomen was opened, to find half a gallon 
of liquid blood within it; and although the vessel was secured, 
and every measure taken to restore the patient, she succumbed 
to the shock. 

The tube is enveloped in two-thirds of its circumference 
by the peritoneum, which forms a mesosalpinx; as the tube 
is enlarged by the developing embryo the mesosalpinx sepa- 
rates. This condition is true only of the internal two-thirds 
of the tube. The external third is not supplied with the meso- 
salpinx. The intraperitoneal rupture is three times as frequent 
as the extraperitoneal. In primary intraperitoneal rupture the 
embryo and its enveloping membranes, or a mole, are dis- 
charged into the abdominal cavity, and a certain amount of 
heraorrhage follows. The amount of blood extravasation 
will depend upon the period of pregnancy when the rupture 
occurs; when early, it may be slight. After the first month, 
however, it is copious, frequently sufficient to cause death 
in a few hours. I saw^ one patient who had missed her period 
but five days. She was taken with violent pain at night, fainted 
several times, and was seen and subjected to operation the 
following morning. She was then extremely anemic, and the 
abdomen was found filled with a large quantity of blood, 
which had escaped from a cyst not larger than a bean in the 
left Fallopian tube. The ligation of the bleeding vessel and 
the removal of the extravasated blood resulted in her restora- 
tion to health. Frequently the hemorrhage may be so great 
as to cause a fatal result in a few hours; in some cases even 
in half an hour. AVhen a rupture is deferred until the seventh 
week, the embryo or mole is not constant^ discharged through 
the opening. The quantity of blood which escapes may be 
very large, and demand immediate attention, or it may be 
slight in character, permitting the patient to escape the im- 
mediate dangers incident to the accident with but 'slight shock. 
The effused blood can undergo absorption and recovery ensue. 
When the discharge is not excessive, the blood collects in the 
rectovaginal fossa and floats the coils of intestine, forming an 
intraperitoneal hematocele, as has been described. Dangers of 
the primary intraperitoneal rupture are: first, hemorrhage 
so great as to cause immediate death; second, the fatal result 
may be occasioned by repeated hemorrhage. In primary 
extraperitoneal rupture that portion of the tube not covered 
by peritoneum gives way and permits the discharge of the 
ovum and the accompanying blood between the layers of the 



542 GYNECOLOGY. 

mesosalpinx. Here the blood is forced into the connective 
tissue between the layers of the broad ligament, and, fortu- 
nately for the patient, the bleeding is checked by the pressure 
from the resisting tissues, and is generally arrested before it 
assumes dangerous proportions. This lesion rarely causes 
trouble. Occasionally, the rupture of the tube is slight, the 
embryo partly escapes, with its membranes remaining un- 
injured, and the pregnancy will continue. Rupture affords 
increased space for further development, and, the power of 
resistance being decreased, the ovum, as it increases in size, 
burrows between the layers of the broad ligament. The rup- 
ture may be gradual; the tube does not split suddenly, but 
as its walls, through the gradual distention, become thinned, 
they yield in the part uncovered by peritoneum until an open- 
ing forms and the ovum is extruded, accompanied by sudden 
hemorrhage. The extent of collapse and its duration will be 
largely dependent upon the amount of blood effused. The 
artificial opening gradually extends, the embryo and placenta 
make their way into the new area, and, unless the hemorrhage 
be sufficient to terminate the life of the embryo, the pregnancy 
is continued. This is known as a mesometric or an intraliga- 
mentary gestation. In this anomalous development of the 
ovum the placenta is liable to many changes which will vitally 
influence the life of fetus and mother. The tubal mucous 
membrane, as has been mentioned, plays a very insignificant 
part in the formation of the placenta. The latter is developed 
mainly from the fetal tissues, as the tube does not develop a 
decidua. With the fecundation of the ovum there are at once 
developed changes in the uterine mucosa in preparation for 
its retention and sustenance. When the fecundated ovum 
is arrested in its progress, and prevented from entering the 
uterus, the uterine decidua continues to develop as if it were 
normally placed. This decidua, however, is rarely retained 
until the completion of gestation, but is thrown off during 
the false labor; not infrequently, when the individual suffers 
from symptoms of tubal abortion or tubal rupture. The oc- 
currence of this profuse bleeding after one or two months' amen- 
orrhea, with the discharge of a cast or of shreds of tissue from 
the uterus, which may frequently be enveloped in a large clot, 
lead the patient and her attendant to believe that a uterine 
abortion has occurred. When the individual goes to term, 
the uterine decidua is thrown off as a cast or in shreds, during 
the early months of the pregnancy. When the decidua is 
discharged in small fragments, it takes place without unusual 
pain; but en masse, the symptoms are similar to those of a 
miscarriage. The absence of the uterine decidua at the death 



ECTOPIC GESTATION, 



543 



of the ovum from rupture of the cyst, even in the early stages 
of pregnancy, is no proof that the membrane has not existed 
and been expelled before fetal death. When pregnancy occurs 
in one-half of a bicornate uterus, the decidua is present in the 
unimpregnated cornu. Under no circumstances, however, either 
in the normal or abnormal pregnancy, is a decidua found in 
the Fallopian tubes. As the destructive changes of the mucous 
membrane of the genital tract associated with menstruation 
are limited to the uterine cavity, so the true decidua is found 
in the same portion. It is sometimes important to avoid con- 
founding the decidua of pregnancy with the cast thrown off 
from the uterus in membranous dysmenorrhea. In the for- 
mer, it consists of a compact layer of decidual cells. In the 
latter, the cast is more 
likely to involve a 
portion of the gland- 
ular structure of the 
uterus. 

Rupture may be 
complete or incom- 
plete. Complete rup- 
ture is one in which 
the ovum and its en- 
velopes escape, either 
into the peritoneal 
cavity or into the 
broad ligament, with 
more or less profuse 
hemorrhage. (Fig. 
427.) A partial rup- 
ture may result in the 
gradual thinning of 
the wall until it gives 
way in one place ; and 

when this takes place extraperitoneally, it is reinforced by plastic 
exudate, with the occurrence of but little, if any, hemorrhage. 
(Fig. 428.) Successive ruptures or partial ruptures thus occur 
until finally the envelope becomes sufficiently distended to per- 
mit the fetus to develop as in an intra-abdominal pregnancy. 
At no time during such a rupture has the separation occurred be- 
tween the placenta and the tube. In the extraperitoneal variety 
the embryo and placenta gradually occupy a sac formed by the 
expanded tube and separated layers of the broad ligament. The 
floor of this space is formed by connective tissue and the leva- 
tor ani muscle. The ultimate effects depend to a great extent 
upon the original situation of the placenta. When the embryo 




Fig. 427. — Complete Rupture of a Tubal Sac. 



544 



GYNECOLOGY. 



is situated above the placenta, the latter is depressed between 
the layers of the broad ligament until it is arrested by the pelvic 
floor. If the embryo lies below, and the membranes burrow 
between the layers of the broad ligament, the placenta is pushed 
up until it lies high in the abdomen. As there is no tubal decidua 
the placental villi lie embedded in the decidual cells without 
any intervillous system existing. When the placenta is dis- 
placed into the tissue of the broad ligament, which occurs 
gradually, its structure becomes seriously damaged: the villi 
are less perfect in their contour, points of extravasation of blood 
are present, and blood-crystals are abundant. Finally, tmder 
the pressure, the placenta becomes gradually reduced to a 
mass of compressed villi ; its serotina is destroyed and is replaced 
by blood-crystals and by organized blood-clot. While the 
consequences to the placenta from its displacement into the 
tissue of the broad ligament are thus marked, it is not attended 

with nearly so much 
danger as when the 
placenta is situated 
above the embryo. 
It is then subject to 
extreme disorganiza- 
tion, forming, as it 
does, the roof of the 
gestation sac. The 
changes that take 
place in the placenta 
owing to the pres- 
sure of the develop- 
ing fetus have a great 
influence on the sub- 
sequent history of the pregnancy, adding to a marked degree 
to the peril to the life of the mother, and are, in the majority of 
cases, disastrous to the life of the fetus. The constant tension 
to which the peritoneum covering the gestation sac is subjected 
leads to partial detachment of the placenta and to severe hemor- 
rhage, either into the gestation sac or into the peritoneal cavity. 
In the later stages of the pregnancy such hemorrhage is al- 
most invariably fatal. A woman with an intraligamentary 
pregnancy, with a placenta situated above the fetus, runs a 
greater risk of losing her life than she would from placenta 
prasvia. A tubal placenta which is situated above the embryo 
has its structure so damaged by rupture as to render it an in- 
eflicient respiratory organ; and the constant results upon the 
embryo are very marked. The fetus from such a gestation 
is rarely a satisfactory individual. It is very unusual for the 




Fig. 428. — Incomplete Rupture of Gestation Sac. 



ECTOPIC GESTATION. 545 

fetus to live longer than a few days or weeks subsequent to 
its delivery. Not infrequently it is ill formed, suffering with 
hydrocephalus, club-foot, spina bifida, ectopia of the viscera, 
and other deformities. When normal in shape, it is exceed- 
ingly defective in size. One case is recorded in which the 
tubal sac contained two embryos, measuring eleven centimeters 
in length, which were united by a band in the thoracic region. 
Dr. M. Price reports a well-formed ectopic fetus which sur- 
vived operation and was subsequently healthy. The amount 
of hemorrhage in an incomplete rupture will depend much 
upon the situation of the placenta. If the placenta be at- 
tached to the peritoneal surface and rupture takes place over 
it, the bleeding will be excessive and will possibly result in the 
death of the patient, unless surgical intervention prevent. 
If the placenta is situated on the opposite side to that on which 
rupture occurs, the envelopes may protrude, but little bleed- 
ing will follow, and the sac becomes reinforced by plastic exu- 
date and adhesions. The sac wall is then formed by the uterus, 
the bladder, the parietal or pelvic peritoneum, and the coils 
of intestine. 

Secondary Rupture. — The extraperitoneal rupture causes 
the formation of a secondary broad ligament gestation sac, 
which increases in size and may subsequently undergo rupture. 
As has already been indicated, the danger is much increased 
when the placenta is situated above the fetus. As the preg- 
nancy progresses the peritoneum becomes stretched and is 
separated from the adjacent parts and from the viscera. The 
sac extends into the abdomen, and strips the peritoneum from 
the anterior abdominal wall to a greater degree than would 
an overdistended bladder. When the posterior peritoneum 
is thus raised up, the rectum, as well as the posterior surface 
of the uterus, may be deprived of serous investment. The 
placenta is insinuated between these parts, and secondary 
rupture may result at any time between the twelfth week and 
the completion of term. The effects of this secondary rup- 
ture are dependent upon the injury to which the placenta is 
subjected. After the middle period of pregnancy has passed, 
when it involves the placenta, — as it almost certainly will, 
situated, as the latter is, above the fetus, — most frightful hemor- 
rhage and rapid death is the consequence. Earlier in the 
course of the pregnancy the hemorrhage is not so severe, and 
may be arrested by prompt surgical intervention. Opening 
of the sac into the peritoneal cavity is recognized as secondary 
intraperitoneal rupture. If the fetus occupies the upper por- 
tion of the sac and the placenta is attached below, the former 
may escape among the intestines. Secondary rupture does 
35 



546 GYNECOLOGY. 

not always occur. The patient may go to term, spurious labor 
follow, the liquor amnii be absorbed, and the placenta dis- 
appear. If the extra-uterine pregnancy has not been sus- 
pected and its course not disturbed, the formation of a mum- 
mified fetus, or lithopedion, results, which may be discovered 
years later. Secondary intraperitoneal rupture may occur 
at any time between the twelfth week and term. When it 
occurs at or near term, the belief is perpetuated that the fer- 
tilized ovum had tumbled into the peritoneal cavity, to in- 
graft itself upon the serous membrane and there develop. It 
should be understood, however, that there is no primary peri- 
toneal pregnancy but that the condition originally developed 
in the Fallopian tube. When the pregnancy develops in the 
uterine end of the tube, particularly that portion which traverses 
the uterine wall, it is termed a tubo-uterine pregnancy. This 
form of pregnancy is not frequent, and can readily be confounded 
with pregnancy in one cornu of a bicornate uterus. The tubo- 
uterine gestation differs in its course, relations, and mode of 
termination from the purely tubal form. Primary rupture 
generally occurs before the eighth week, and the pregnancy 
is rarely continued without rupture beyond the twelfth week. 
The tubo-uterine gestation sac may rupture in two directions: 
into the peritoneal cavity, causing frightful hemorrhage and 
a rapidly fatal result, or, resistance being slighter toward 
the uterine cavity, the fetus and envelopes may be pushed 
into the uterus and terminate as in an intrauterine conception. 
The intraperitoneal rupture is much more rapidly fatal than 
in the tubal form, and causes more severe hemorrhage, because 
the uterine wall is more vascular and the sac is situated in 
closer apposition to larger vessels. Tubal and tubo-uterine 
pregnancy have the following distinctive characteristics: the 
tubal pregnancy is very common, the tubo-uterine rare; the 
tubal gestation sac is very thin, the tubo-uterine very thick. 
The termination can be: (a) Intraperitoneal rupture for 
each, or (b) rupture into the intraligamentary space. In the 
tubo-uterine, rupture can occur into the uterine cavity, with 
the discharge of the fetus through the vagina, (c) In the tubal, 
abortion can result, and, as in the primary rupture, date from 
the third to the twelfth week. In the tubo-uterine, rupture 
occurs at any time from the fifth to the twentieth week. Ovarian 
pregnancy, pure and simple, is extremely rare, and while there 
are cases in which careful examination has disclosed ovarian 
structure in the sac wall, with the tube free and unaffected, 
yet we are not prepared to admit that the condition may not 
have originated from the tube, for it is very doubtful whether 
the ovum will develop when not attached to the Mullerian 



ECTOPIC GESTATION. 547 

structure. The majority of cases of ovarian pregnancy are 
undoubtedly tubo -ovarian, in which the embryo was originally 
situated in the orifice of the tube and has been partly extruded 
without loss of its vitality. As would be readily inferred, 
the life of the embryo in a tubal pregnancy is necessarily pre- 
carious. After rupture, undoubtedly the pregnancy may con- 
tinue until full term. Symptoms of labor set in, during which 
the gestation sac may burst into the peritoneal cavity, or, 
if this catastrophe is avoided, the fetus dies. The body re- 
mains quiescent or produces various forms of disturbance. 
Thus, the liquor amnii is absorbed; the tissues of the fetus 
become mummified or partly calcified, and form a lithopedion. 
The softer parts are converted into adipocere or undergo other 
forms of decomposition. The placental tissue is gradually 
absorbed and disappears. 

Mummification. — The process of mummification is attended 
with absorption of the fluids, while the soft parts are converted 
into a dried tissue similar to that which follows when a dead 
cat is permitted to remain under an old building, producing 
a dried cat. An extra -uterine fetus can be retained in the 
body for a longer period of time. Cheston reports a lithopedion 
carried for fifty-two years; Barnes, one forty-two. The pos- 
sibility of the fetus being carried this length of time does not 
necessarily indicate that it can not prove a source of danger 
to the patient. Pathogenic micro-organisms can find entrance 
to the sac through the adjacent hollow viscera, and at any 
time produce serious trouble. Suppuration follows, and pus 
finds its way through the sac-wall, and penetrates the va- 
gina, uterus, bladder, or rectum. Through any of these open- 
ings fragments of fetal tissue from time to time escape, caus- 
ing frightful distress and necessitating operation for relief. 
The existence of a lithopedion or macerated fetal skeleton 
does not preclude subsequent pregnancy. One case came 
under my observation in which a woman with a good-sized and 
distinctly well-defined lithopedion subsequently gave birth to 
two children. 

481. Symptoms. — The symptoms of an ectopic gestation 
are dependent upon the duration and course of the pregnancy. 
Prior to rupture the symptoms are those of an ordinary preg- 
nancy, excepting a sense of uneasiness in the affected side, 
with frequent and sudden attacks of colicky pains. In many 
patients the first indication of the pregnancy being abnormal 
will be an attack of pain so severe and lancinating in character 
as to cause the patient to lose consciousness. In severe cases 
the patient falls back unconscious, and is covered at once with 
a cold, clammy perspiration; presents symptoms of most pro- 



548 GYNECOLOGY. 

found anemia and a sighing or gasping respiration; when con- 
scious, complains of intense pain in the lower abdomen and 
pelvis; has a frequent, feeble, scarcely perceptible pulse and 
dilated pupils; complains of loss of sight — of everything being 
dark about her; attacks of syncope recur; and, unless the con- 
dition is promptly recognized and intervention practised, death 
follows. Occasionally, the symptoms are not so marked; the 
patient is weak, debilitated, shows symptoms of shock or col- 
lapse, soon rallies, with recurring attacks of a similar character, 
which indicate that the hemorrhage has again recurred. In 
other cases the progress of the case is insidious; a small aper- 
ture has occurred, the walls have been stretched, and the preg- 
nancy may progress without further accident. The tube may 
have ruptured intraperitoneally or extraperitoneally. The symp- 
toms of the two varieties are entirely different, and the gravity of 
the symptoms of the intraperitoneal variety will depend upon 
whether the rupture has been complete or incomplete, and 
also upon the situation of the placenta. When the rupture 
occurs over the placenta, even though incomplete, hemorrhage 
can be so severe as to cause the death of the patient if inter- 
vention is not instituted. If the patient survives the hemorrhage 
and shock, the accident is followed by more or less tender- 
ness over the abdomen and by abdominal distention, which 
are indications of localized peritonitis. The sac becomes en- 
cysted, and intraperitoneal hematocele follows. In the extra- 
peritoneal variety the symptoms are not nearly so marked; 
the indications of collapse are slighter, the patient rallies more 
quickly, and the resistance of the tissues limits the amount 
of bleeding. The distressing symptoms are often so slight as 
scarcely to lead the patient to apply for examination; and 
when examination is made, it is more likely to be with the pur- 
pose of determining the existence of pregnancy than the oc- 
currence of an abnormal location for the embryo. With the 
occurrence of symptoms of rupture there is not infrequently 
a discharge of blood from the vagina, which is generally associ- 
ated with uterine pain. The uterine pain or the pain arising 
from rupture may cause the individual to believe that an abor- 
tion is about to occur. This suspicion is still further confirmed 
by the discharge of a cast of the uterus or of shreds of tissue 
associated with clots, which may deceive both the patient 
and her attendant into the belief that an abortion has occurred. 
When the hemorrhage is slight and the ovum retains its con- 
nection with the tube, the fetus may go on to full develop- 
ment, and may reach full term. The pregnancy, especially 
when it is situated posterior to the uterus, may reach full term 
without leading the patient to the suspicion that an abnormal 



ECTOPIC GESTATION. 549 

condition exists, and it is only after the beginning of labor, 
when an examination is made, that the true state of affairs 
is recognized. Even then it is not always recognized, and 
the spurious labor may terminate without the discharge of 
the fetus and the sac may undergo subsequent changes. 

482. Diagnosis. — Diagnosis comprises: (i) The recognition 
of extrauterine pregnancy prior to rupture ; (2) the determination 
of rupture or abortion with intraperitoneal or extraperitoneal 
hemorrhage and death of the fetus; (3) secondary rupture; 
(4) continued growth of the embryo after rupture; (5) peritonitis; 
(6) suppuration. 

I. Most frequently the victim of misplaced conception 
does not apply to her physician until the occurrence of a vio- 
lent, tearing pain, associated with rupture. The distressing 
symptoms are rarely sufficient prior to this occurrence to de- 
mand a physical examination. Such an examination is generally 
requested in order to ascertain the existence of the supposed 
normal pregnancy. The frequent occurrence of ectopic ges- 
tation, however, should lead to the careful investigation of 
every patient w^ho gives symptoms of being pregnant, where 
there is a previous history of more or less extended sterility, 
of attacks of pelvic inflammation, and, especially, if the latter 
has originated from gonorrheal infection. Such an examina- 
tion is particularly indicated when the patient, having missed 
a period, complains of a sensation of uneasiness or distress in 
one side of the abdomen, associated with frequent and sudden 
attacks of colicky pain. Every such patient should be sub- 
jected to a careful examination. Slight enlargement of the 
uterus, with some tenderness in the pelvis, more marked upon 
one side, associated with a more or less spherical or rounded 
distention of the tube, should increase the suspicion of ectopic 
gestation. This suspicion would be confirmed by finding 
increased vascularity in the broad ligament, causing marked 
pulsation of its vessels. This pulsation is distinctly recogniz- 
able upon the affected side, while the pulsation on the opposite 
side is not defined. The examination should be made with 
the utmost gentleness, for rough manipulation or marked pres- 
sure in the practice of the bimanual procedure can very readily 
rupture a sac which is so thin as only to require a slight amount 
of additional pressure. Where the sac is of considerable size, 
it is unwise to subject it to much force in the examination, un- 
less the operator is prepared for immediate operation should 
rupture occur. It has been my unfortunate experience with 
a patient in whom the pulsation was as distinct as if the finger 
were placed over the radial artery, to have the sac ruptured 
by her physician, who was desirous of examining the case. 



550 GYNECOLOGY. 

The patient succumbed to the subsequent operation. Dr. 
J. M. Fisher, my assistant, reports two cases in which he has 
observed the rupture of an ectopic gestation during examination. 
2. Rupture. — The rupture of an ectopic gestation sac may 
be suspected when the patient gives a history of having failed 
to menstruate for one or two periods and has exhibited the 
ordinary symptoms of pregnancy. She has probably had 
more or less discomfort upon one side, with frequent colicky 
attacks, when suddenly, without warning, there has been an 
attack of most violent, tearing pain, followed by syncope, all 
the symptoms of internal hemorrhage, with oncoming collapse. 
I have seen such a patient in the space of ten minutes pass 
from a condition of apparent good health to one which seemed 
to threaten approaching dissolution. The face was blanched, 
pale, exceedingly anxious looking, covered with cold, clammy 
perspiration; pupils dilated, eyes expressionless, rolling from 
side to side; sighing respiration; pulse rapid, feeble, some- 
times almost imperceptible; patient complaining of being un- 
able to see, and everything appearing dark about her. Some- 
times marked nausea and vomiting are present. The slightest 
movement, even raising the head of the patient, is followed 
by more or less profound syncope. The occurrence of such 
a train of symptoms should awaken in the mind of the ob- 
server the absolute conviction that an internal hemorrhage 
is occurring, and the association of such a group of symptoms 
would indicate its origin from an ectopic gestation. A phys- 
ical examination affords very little information, for at this 
time the tumor is insufficiently large and without the necessary 
firmness to afford the sensation of resistance. The physical 
signs are consequently indefinite. When the bleeding is ex- 
tensive, the abdominal walls thinned and not very resistant, 
a sensation of distention may be noted and even fluctuation 
recognized. When the hemorrhage is not so profound as to 
endanger life, the watery portions of the effused blood are 
gradually absorbed and leave a more or less resistant clot, 
which can be felt as a firm mass in the pelvis. In the absence 
of previous history of recent inflammatory trouble, or the pre- 
vious existence of a growth, it must be recognized as effused 
or clotted blood. The accumulation is generally retro -uterine. 
A large extravasation may fill the pelvis, push the uterus for- 
ward, and raise the intestines above it (Fig. 429). In other 
cases the uterus may be found in a state of retroversion, while 
a mass is situated in front and forms an ante-uterine hemato- 
cele; or in very large accumulations the uterus may protrude 
through it, producing what is known as a circumuterine hemato- 
cele. Hemorrhage dangerous to life, and productive of the 



ECTOPIC GESTATION. 



551 



most profound anemia, may arise without rupture, as in tubal 
abortion, or when the villi have penetrated the wall of the 
tubal sac and bleeding occurs from their surfaces. These per- 
forations may be so minute as to be unrecognizable by the 
naked eye, except for a thrombus projecting from the external 
tubal surface. The tubal abortion in its earliest stage causes 
no marked physical manifestations outside of those symptoms 
which indicate an internal hemorrhage. Later, however, the 
blood-clots in the tube, filling up the "sac, produce a large sausage- 
shaped mass, which may be firm and resistant. The patients 
in whom rupture has occurred may present successive attacks 
of shock and syncope. Thus, a patient bleeds until the blood 
pressure is greatly reduced, a clot forms, plugs the vessel tem- 
porarily, and the circulation is restored. If, however, injudicious 




Fig. 429. — Ectopic Gestation Sac Ruptured, showing Fetus. 



efforts are made to revive the patient by hypodermic injections 
of strychnin, digitalin, or intravenous injection of salt solution, 
the clot is washed or driven out and hemorrhage again recurs 
with a repetition of the former symptoms. Noble has reported 
cases in which the rupture and hemorrhage have been associated 
with a rather rapid and marked rise of temperature. The 
general rule, however, is that where hemorrhage is marked 
the patient shows a subnormal temperature, as would be ex- 
pected in cases of shock and threatened collapse. The tem- 
perature rarely is elevated until some days after the hemor- 
rhage, and then is not high. The elevation of temperature 
is undoubtedly due to degenerative changes in the collection, 
possibly from the fibrin ferment, or more likely from partial 



552 GYNECOLOGY. 

infection by organisms from the intestinal canal. At the time 
of this elevation of temperature the peritoneal exudate is thrown 
out, which forms barriers and confines the blood accumulation 
within the pelvis. The watery portions of the blood become 
absorbed, so that we have a more or less distinct and well-defined 
mass of clotted blood. In extraperitoneal hemorrhage the 
symptoms are much less acute. Shock or collapse is less marked, 
although we still have symptoms which, to a limited degree, 
should lead one to suspect internal hemorrhage. In such a 
case examination will disclose on one side of the pelvis a mass 
which may fill up and distend the broad ligament. The tumor 
may be quite tense and push the uterus to the opposite side. 
The condition differs from tubal disease in that the broad liga- 
ment is distended by it. There has been an absence of recent 
inflammatory trouble, and the patient does not present the 
characteristic symptoms of inflammation. In the intraperi- 
toneal variety the irritation of the accumulated blood causes 
certain reactive symptoms and sometimes the development 
of peritonitis. The temperature becomes elevated, pulse rapid, 
the abdomen tender and sensitive to pressure. But the symp- 
toms are not so acute and severe as in marked inflammation. 
The rupture and internal hemorrhage are usually associated 
with a discharge from the uterus of decidual membrane, either 
as a complete cast of the cavity or in the form of shreds mixed 
with clots. The cast may show the orifice of the Fallopian 
tubes and internal os. Inquiry should be made with regard 
to this symptom, and, when possible, the discharged material 
should be carefully examined. It is important to differentiate 
it from the decidua thrown off in some forms of dysmenorrhea. 
That of pregnancy is from six to eight millimeters in thick- 
ness, while that of menstruation rarely exceeds two or three 
centimeters in length and is scarcely two millimeters in thick- 
ness, is translucent, is rarely passed entire, and consists of the 
compact layer of the epithelium. When the symptoms have 
been slight and the woman has considered herself the subject 
of an abortion, it is not until the enlarged fetal sac causes a 
suspicion of the continuation of the pregnancy that the patient 
will present herself for examination, and even then she may 
not consult a physician. 

3. Secondary Rupture. — Secondary rupture necessarily fol- 
lows a primary rupture, which, in the majority of cases, has 
taken place in the broad ligament. The rupture has occurred 
in such a way as not to interfere with the vitality of the ovum. 
Retaining its vitality, it enlarges its implantation, and in its 
■growth spreads out the broad ligament until the latter is no 
longer able to retain it, when from pressure the thinned wall 



ECTOPIC GESTATION. 553 

finally ruptures and severe hemorrhage takes place into the 
peritoneal cavity. The history of repeated attacks of pain 
and distress, of symptoms of internal hemorrhage, of the en- 
larging abdomen, and, finally, the cutting, agonizing pain 
associated with rupture into the peritoneal cavity, should be 
sufficient data upon which to base the diagnosis of secondary 
rupture. Both in primary and secondary rupture the amount 
of hemorrhage will depend upon its relation to the site of the 
placenta. Where the rupture takes place over the latter, 
the hemorrhage may be very profound and so rapid as to re- 
sult in death of the woman before measures can be instituted 
for her relief. 

4. Continued Growth of the Embryo after Rupture. — ^Vs has 
already been seen, this groAvth may take place into the broad 
ligament, spreading it out, or in those cases in which the embryo 
has become reimplanted upon the surface of the peritoneum, 
the ovary, or in a continuation of the tube, we may have the 
growth advancing as we would in ordinary pregnancy. The 
fetal movements are recognized, the enlargement continues, 
and the patient imagines herself normally pregnant. On 
physical examination of such a patient, the parts are more dis- 
tinctly defined by bimanual palpation than if the mass were 
situated within the uterus, as there is less structure intervening 
between the fetus and the palpating hand. The recognition 
of the fetal heart sounds is an absolute indication of the ex- 
istence of pregnancy. With the completion of the normal 
term of pregnancy in such a patient, w^e have the occurrence 
of spurious labor, cessation of fetal movements, and changes 
occur which, coming under observation months later, may 
increase the obscurity of the condition. 

A patient came under my observation who supposed her- 
self pregnant, and who suffered from a bloody discharge, with 
considerable pain, at the end of the second month, which led 
her to think that an abortion had occurred. The supposed 
abortion occurred in February. Her abdomen consequently 
became enlarged, and in the following October she went into 
labor. Pains continued for tw^o days, and after the move- 
ments ceased her menstrual periods returned. In April, when 
she came under my observation, she presented a tumor as 
large as in a pregnancy at full term, over which there was dis- 
tinct fluctuation and marked resonance. A thin- walled sac 
was recognized, but there was no sign of a resistant mass. Va- 
ginal examination disclosed behind the uterus a tumor which 
filled Douglas' pouch. The uterus was enlarged and was situ- 
ated directly in front of the tumor. On percussion, there 
was resonance everywhere. No dullness could be distinguished. 



554 GYNECOLOGY. 

although fluctuation was distinct. The diagnosis was an ectopic 
gestation, with death of the fetus, decomposition in the fetal 
sac, and the formation of gas. This diagnosis was confirmed 
by opening the abdomen and finding posterior to the uterus 
a sac which contained a macerated fetus and a considerable 
quantity of offensive fluid. 

5. Peritonitis. — Peritonitis may take place as a result of 
rupture of the sac, the escape of its contents into the peritoneal 
cavity, the accumulation of blood from a large hemorrhage, 
and its irritation upon the pelvic peritoneum. Unless relief 
is afforded, extensive matting together of the intestines and 
pelvic structures occurs, which will require early operative inter- 
ference for relief. Peritonitis may be produced, also, by the 
death of the fetus and infection of the sac. Its occurrence 
is indicated by pain and tenderness over the abdomen, the 
distention of the belly, assumption of the dorsal position, dis- 
tress during the evacuation of the bladder or movement of 
the bowels. 

6. Suppuration. — Suppuration in an ectopic gestation may 
follow its rupture, so that the contents of such a sac becomes 
sanguino-purulent. Suppuration also takes place in later stages 
of a pregnancy which has gone on to full term; the fetus has 
subsequently become macerated, mummified, or even a lith- 
opedion has formed. Suppuration may take place months or 
even years after the occurrence of a pregnancy, leading to the 
evacuation of the sac or to its rupture into the intestine, the 
bladder, the vagina, or through the abdominal wall. In such a 
case the fragments of the fetus and its bony structure will be 
discharged. Suppuration will be indicated by increased pain 
and distress, by recurring chills, sweating, elevation of tem- 
perature, and the ordinary symptoms associated with sup- 
purative processes. That the suppuration has originated in 
an ectopic gestation will be demonstrated by the previous 
history of the case. This is made absolutely certain when 
the bony fragments of the fetus are discharged. 

483. Differential Diagnosis. — Tubal and uterine pregnancy 
may coexist. Uterine pregnancy may follow tubal, or re- 
peated uterine pregnancies may occur subsequent to the for- 
mation of a lithopedion. Tubal pregnancy may be bilateral. 
Its frequent occurrence in the remaining tube after removal 
of a tubal gestation sac has led some operators to advocate 
the removal of both appendages in every case of tubal gesta- 
tion. Tubal pregnancy may coexist with ovarian and tubo- 
ovarian tumors. In a case I saw with Dr. J. M. Fisher the 
symptoms justified his diagnosis of rupture of a tubal gesta- 
tion sac. From its outline a mass upon the left side of the 



ECTOPIC GESTATION. 



555 



pelvis was considered to be a large extraperitoneal hemato- 
cele, which I decided to evacuate by a vaginal incision. A 
large quantity of clotted blood was evacuated, above which 
was a smooth cyst, too large to remove through the vagina. 
The ruptured tubal gestation sac was upon the opposite side. 
The removal of the cyst was effected by an abdominal incision. 
The following conditions may be confounded with ectopic 
gestation: first, uterine pregnancy; second, pregnancy in a 
bicornate uterus; third, a retrofiexed gravid uterus; fourth, 
spurious pregnancy; fifth, ovarian tumors; sixth, uterine tumors; 




Fig. 430. — Large Ectopic Gestation Sac. 



seventh, intraligamentary tumors; eighth, accumulation of 
feces in the rectum. 

First, uncomplicated uterine pregnancy is generally more 
easily recognized by the change in shape and size of the organ. 
In ectopic gestation the jug-like shape or outline of the fundus 
is wanting. A sac or mass rather sharply defined will be found 
in one of the tubes, if rupture has not occurred, and the sub- 
jacent vessels will pulsate more distinctly than upon the oppo- 
site side. After rupture the condition is distinguished by 
more or less severe shock, profound anemia, and the appear- 
ance of a large mass in the pelvis without a history of previous 
inflammatory phenomena. The introduction of the sound 



556 GYNECOLOGY. 

and the use of the curet to secure decidual tissue have been 
advocated, but are procedures which are not free from danger. 
In possible uterine pregnancy and abortion the danger of in- 
fection must not be overlooked. The investigation for decidua 
may be misleading, as it may have been previously exfoliated. 
The tissue removed by a curet cannot be certainly distinguished 
from that which will be caused by inflammation, and the pro- 
cedure endangers the development of septic processes, which 
will complicate a tubal gestation if any exists. 

Second, pregnancy in one horn of a bicornate uterus may 
be impossible to differentiate from a tubo-uterine or an inter- 
stitial pregnancy. Fortunately, the treatment of the two 
conditions is similar, and is almost equally urgent. A tubal 
gestation is situated at a greater distance from the uterus. 

Third, the retrofiexed pregnant uterus is recognized by 
palpation, in which we are able to trace the tumor back from 
the cervix, and the smoothly outlined fundus is capable of 
considerable movement. 

Fourth, careful analysis of the symptoms, associated with 
the accurate consideration of physical signs, will guide to a 
correct diagnosis. It is a grave error to mistake, after the ab- 
domen has been opened, an extraperitoneal pregnancy for 
sarcoma or myoma. 

Fifth, ovarian tumors are usually differentiated by their 
history. It is only when one of these growths has produced 
no symptoms by which its presence could be suspected, and 
is suddenly complicated by an acute attack, during which 
or subsequent to which examination discloses its presence 
more or less fixed in the pelvis, that error is possible. Such 
a train of symptoms is readily produced by twisting of the 
pedicle of a small ovarian or a broad ligament cyst. A young 
unmarried woman came under my observation with a history 
of having had a severe attack of pain upon the right side, which 
was pronounced appendicitis. While a movable mass could 
be felt above the brim of the pelvis upon the right side 
there was no indication of inflammatory exudation. Not- 
withstanding the good character of the individual, ectopic 
gestation was regarded as a possibility. An abdominal incision 
disclosed a broad ligament cyst beyond the ovary, closely 
attached to the outer part of the tube, whose pedicle had twisted, 
causing hemorrhage into the cyst and twisted portion of the 
tube, with the effusion of a large quantity of bloody serum 
free in the peritoneal cavity. 

Sixth, when, in an extra-uterine pregnancy, the fetus is 
dead, the fluid portions have been absorbed, and the mass 
is hard and firm, with its sac closely adherent to the side of the 



ECTOPIC GESTATION. 557 

uterus, the physical signs are frequently insufficient to establish 
the differential diagnosis between it and an intraligamentous 
myoma. 

Seventh, intraligamentary tumors are easily confounded 
with ectopic gestation. Frequently the diagnosis can be deter- 
mined only after abdominal incision. A patient was brought 
to me with the following history: She had been married nine 
years and had never been pregnant ; six weeks before admission 
she was seized with severe pain in the left side, and subsequent 
inflammatory symptoms, which confined her to bed the greater 
portion of the time. A mass, quite resistant, was felt to the 
left and in front of the uterus, which was firmly fixed by ad- 
hesions. The long period of sterility, sudden onset, and more 
or less fixed tumor, not previously recognized, led me to sus- 
pect tubal gestation, with intraligamentary rupture. The 
incision, however, disclosed an intraligamentary ovarian cyst 
with thick walls, which had undergone a degenerative pro- 
cess, and which probably explained the sudden onset. 

Not infrequently the diagnosis can be determined only 
by incision, and an ectopic gestation is found when opera- 
tions are performed for other conditions, and the reverse. 

Eighth, careful examination should exclude fecal accumu- 
lation; ordinarily, the latter condition is determined by the 
possibility of indenting the fecal masses. When there is any 
doubt, an expression of opinion should be withheld until a 
complete evacuation of the bowels can be secured through 
the employment of an active purgative, supplemented by 
free rectal enemata. 

The differential diagnosis of tubal rupture is often difficult. 
Rupture is simulated by lesions of the abdominal viscera, such 
as perforating ulcers in the stomach, duodenum, small in- 
testine, and vermiform appendix; rupture of a pyosalpinx; 
torsion of the pedicle of a small ovarian cyst; acute intestinal 
obstiniction ; renal and biliary colic. A case of tubal gestation 
has been brought to operation as a supposed strangulated 
hernia. The diagnosis of tubal rupture can always be rendered 
certain by a puncture through the posterior vaginal fornix, 
when the rupture will be indicated by the discharge of dark- 
colored blood. The vaginal puncture affords, in addition, 
opportunity for the digital exploration of the pelvic viscera. 
Such an investigation permits palpation of the tubes and ovaries 
and the recognition of existing abnormalities. 

The following table, modified by Gregg Smith from Web- 
ster, presents in a convenient form a summary of the pathologic 
and clinical features of ectopic gestation: 



558 GYNECOLOGY. 

A. Ampullar — Gestation beginning in the ampulla of the tube. 

I. Persisting (rarely goes to full term). 
II. Rupture (the usual result) : 

1. Into broad ligament: 

(a) Gestation continues there. 

(6) Secondary rupture into peritoneal cavity. 

{c) Gestation terminates: 

{a') By formation of hematoma. 

(60 By suppuration. 

(c') By mummification. 

2, Into peritoneal cavity: 

(a) Gestation continues, the placenta remaining in the tube, the 

fetus and the membranes being in the cavity. 
(6) Gestation terminates: 

(a') The patient dying from hemorrhage or shock. 
{b') By absorption of the mass. 

{c') By mummification or by adipocere or lithopedion forma- 
tion. 
III. Destruction of gestation: 

1. By tubal abortion. 

2. By formation of mole. 

3. By hematosalpinx. 

4. By suppuration. 

5. By absorption after early death. 

B. Interstitial, when the gestation develops in the interstitial portion of 

the tube: 
I. Persisting (the gestation may go on to term). 
II. Rupture- 

1. Into the peritoneal cavity. 

2. Into the uterine cavity. 

3. Into both the peritoneal and uterine cavities. 

4. Between layers of broad ligament. 

III. Destruction of gestation and regressive changes in fetus and envelopes. 

C. Infundibular, when the gestation is in the outer end of the tube. 

The ovary may form part of the wall of the sac. 

484. Prognosis. — Extra-uterine pregnancy at any stage of 
its progress must be regarded as a condition pregnant with 
the greatest peril to the individual. It should be regarded 
as just as positive an indication for treatment as would be 
the presence of malignant disease. If discovered before the 
rupture of the sac, the patient is in danger from hemorrhage. 
The longer the condition progresses, the more grave is the 
peril. After rupture, with death of the fetus, the patient is 
not free from danger, as the collection of blood — the hemato- 
cele — may become infected, from its proximity to the hollow 
viscera, and cause the formation of an abscess or the develop- 
ment of pyemic symptoms. If the fetus survives the rup- 
ture, its subsequent development only increases the danger. 
A secondary rupture, with escape of the sac contents into the 
peritoneal cavity, or the frightful hemorrhages which result 
in some conditions, may prove immediately fatal. The woman 
goes on to full term; the fetus dies, then undergoes retrogressive 
processes, which may at any time, even after years of quies- 
cence, become infected, resulting in the formation of abscesses, 



ECTOPIC GESTATION. 559 

perforation of viscera, and escape of the contents of the sac. 
As the nutrition of the fetus in the majority of cases is defec- 
tive, from unfavorable implantation of the placenta, frequently 
from pressure upon it, the fetus is generally imperfectly devel- 
oped, often undersized, stiff ering from hydrocephalus, spina 
bifida, club-foot, and other deformities. The preservation of 
the life of such an individual should not be considered when 
it is recognized that the life of the mother is constantly in peril. 
Furthermore, the fact that, even under the most favorable 
circumstances, the chances for the fetus are very greatly de- 
creased, and that, even when delivered alive, its duration of 
life is short, should be taken into account. The statistics of 
Dunning indicate that an operation for the delivery of the 
child during life, when viable, is more favorable for the life 
of the mother than is the delay of the operation until after 
the death of the fetus. 

485. Treatment. — In a condition fraught with such dangers 
as that of ectopic gestation it does not seem the province of 
the physician to practise any other method than one which 
will afford the greatest certainty of relief and which can be 
accomplished with the least danger. This, in our judgment, is 
through surgical manipulation; but, as other methods of treat- 
ment have been advocated, before entering upon the considera- 
tion of extirpation we will consider the substitutes. The sub- 
stitute methods recognized are evacuation of the liquor amnii, 
injection of poisonous substances, elytrotomy, and the ap- 
plication of the electric current. 

The evacuation of the liquor amnii was advocated by Simp- 
son in 1864. He treated a case by puncturing the cyst through 
the vagina without killing the child, and the mother died in 
three days. Braxton Hicks tried a similar method in 1865, 
which killed the child, but the mother died of hemorrhage. 
Greenhalgh, in 1867, had a successful case. James, of Phil- 
adelphia, in 1867, had a successful case after much tribulation. 
This plan of treatment, owing to the great mortality, has been 
generally abandoned. 

The injection of poisonous materials into the fetus and 
its enveloping fluids was advocated by Joulin in 1863. Morphin 
is the drug most frequently used. Other remedies, such as 
strychnin and ergotin, have been similar h^ employed. In- 
unctions of mercury and iodid of potash and repeated bleed- 
ing have been advocated, but it is difficult to explain why. 
The injection of morphin with a hypodermic syringe is practised 
before the fifth month. Two injections are usually given, 
containing -^ of a grain each, at an interval of from eight to 
fifteen days. The treatment may result in severe hemorrhage, 



560 GYNECOLOGY. 

septicemia, and perforation of an intestinal loop, so that, while 
apparently a simple procedure, it is attended with greater 
danger than an abdominal operation. 

Ely trot omy, or the removal of the fetus and its contents 
through a vaginal incision, was instituted as early as 1817 by 
Dr. King, of Georgia. This operation, which has been lately 
revived, is not by any means a new one. In the discussion of 
hematocele vaginal incision has been advocated as a justifiable 
method of procedure when the condition has become chronic; 
in other words, some time after the hemorrhage has taken 
place, when the vessels are occluded and the fetus is more than 
likely to be dead. In such cases vaginal incision affords an 
opportunity for clearing away the debris without subjecting 
the patient to so serious an operation as would be that through 
the abdominal wall. But before rupture, or immediately 
following rupture, in order to arrest the hemorrhage, the ab- 
dominal incision should be preferred. When the patient has 
reached full term, and the death of the fetus has occurred, but 
as yet without the appearance of suppuration, the vaginal pro- 
cedure may be chosen: (i) When the fetus presents the head, 
breech, or feet, so that it can be extracted without altering 
its position; (2) when it is certain, from the thinness of the 
structures separating the presenting part from the vaginal 
canal, that the placenta is not situated over this part of the 
sac, and we are not absolutely certain that the placenta may 
not be inserted on the anterior abdominal wall. If it is neces- 
sary to turn the child in order to deliver it, the vaginal pro- 
cedure should not be considered. Robertson advocates dividing 
the perineum, septum of the vagina, and rectum, but this is an 
unnecessarily severe proceeding. 

The application of electricity for the destruction of the 
fetus has been practised since 1853. There is a difference of 
opinion, however, among electrotherapeutists as to the greater 
value of the faradic and galvanic currents, each having its 
advocates. This procedure is preferable to all those which 
have been named, but is advisable only in the earlier months 
of pregnancy. In the early stages we must take into con- 
sideration the fact that the diagnosis is not always certain. 
Without doubt, many of the cases reported to have been cured 
by electricity were cases which had undergone rupture, and 
in which the tubal mole or embryo had escaped and lost its 
vitality, and the electric treatment has possibly served to ex- 
pedite the absorption of the exudation— an absorption which 
would have taken place had electricity not been applied. Many 
cases in which electricity has been applied were undoubtedly 
cases of mistaken diagnosis. It is true that advanced methods 



ECTOPIC GESTATION. 561 

of examination will more certainly differentiate the condition, 
but the violence required to accomplish this will greatly en- 
danger the rupture of the fetal sac. The application of electric- 
ity has occasionally been found to intensify the contraction 
of the muscle-fiber of the tube and to result in rupture and 
severe hemorrhage. When the death of the fetus occurs the 
danger does not cease, and we will frequently find the placenta 
continuing to grow, or rupture may follow, associated with 
severe hemorrhage and later with septicemia. In the applica- 
tion of the current one pole of the battery, generally the neg- 
ative, is applied through either the rectum or the vagina in 
the neighborhood of the ovum. The other pole or a large 
electrode is applied to the abdominal wall directly over the 
sac and an inch or more above Poupart's ligament. The cur- 
rent is used for from five to ten minutes, increasing it as the 
sensitiveness of the patient will permit. When necessary, 
the application should be repeated. The practice of this pro- 
cedure is of doubtful utility, and, as has already been men- 
tioned, it is not without danger. It temporizes with a condition 
which menaces life and may excite severe tubal contractions 
which often result in rupture with subsequent hemorrhage. 

The risks and difficulties of operative treatment will largely 
depend upon the stage of gestation and the condition of the 
placenta and gestation sac. The surgeon, to be properly prepared 
to meet all emergencies, should consider the following: (i) 
The measures to be employed before primary rupture or abor- 
tion; (2) the measures required at the time of primary rupture; 
(3) what shall be done for the patient coming under obser- 
vation subsequent to rupture, (a) with intraperitoneal hemor- 
rhage; (b) with extraperitoneal hemorrhage; (4) the method 
of treatment advisable in advanced growth of the embryo, 
(a) the child alive; (6) the child dead, mummified, or reduced 
to a lithopedion; (c) following decomposition of the fetus and 
suppuration of the sac. 

I. The Measures to be Employed before Primary Rupture or 
Abortion. — Cases in which opportunity is afforded to operate 
prior to the rupture of the sac are more frequent than formerly, 
owing to our improved methods of diagnosis and to the greater 
significance given to disorders accompanying the pregnancy. 
Too frequently, still, the disorder will be overlooked until the 
danger-signal of rupture appears. When the symptoms pres- 
ent make it evident that an ectopic gestation exists or is ex- 
tremely probable, the patient should be subjected to operation 
at the earliest possible moment. The danger arising from 
rupture is so great that the patient should be considered in 
peril of her life until the condition is corrected. The abdominal. 

36 



562 GYNECOLOGY. 

incision is the preferable procedure, inasmuch as it affords a 
better opportunity to explore the field, to manage adhesions, 
and to secure bleeding vessels. The removal of the entire 
sac rarely affords any special difficulty . In a tubo-ovarian 
pregnancy it is possible that a knuckle of intestine may have 
become adherent to the sac. In such cases the removal of 
the latter must be carefully managed, because the changes 
which take place in the adherent intestine render it easily torn. 
Failure to recognize this possibility in my own experience led 
to the necessity of resecting a knuckle of intestine for an ex- 
tensive tear. The patient, however, fortunately recovered. 

2. The Measures Required at the Time of Primary Rupture. — 
Unfortunately, the attention of the physician is much more 
frequently directed to the occurrence of primary rupture or 
abortion rather than to the existence of an ectopic gestation 
prior to this event. Very frequently the efforts employed 
to arrive at a correct diagnosis may be the means of the pro- 
duction of this catastrophe. Therefore, I would again em- 
phasize the importance of delicate manipulation in a case of 
suspected ectopic gestation. Indeed, prior to the careful 
examination of a patient in whom an extrauterine pregnancy 
is suspected, it would be well to have ample provision for re- 
sort to immediate surgical procedure, in the event of collapse 
or rupture of the ectopic sac. Should the disaster occur during 
an examination, or the physician be called upon to attend a 
case in which rupture had recently occurred, he should endeavor 
to keep the patient perfectly quiet and free from annoyance, 
with her clothing loosened. The foot of her bed should be 
elevated and a hypodermic injection of morphin should be 
administered with a view not only to quiet the pain, but to 
lessen the nerve irritability and restlessness. An ice-bag should 
be applied over the abdomen and immediate preparations 
made for opening the abdomen, in order to secure the bleeding 
vessel. The patient should be placed under the influence 
of an anesthetic. If the operator is at all in doubt as to whether 
the condition has resulted from an internal hemorrhage, he may 
confirm his suspicions and satisfy all scruples by cleansing the 
vagina and making a puncture through the posterior fornix, 
which will permit the recognition of the escaping blood. In- 
deed, through such a puncture the tubes may be examined 
and the presence of the sac recognized. Moreover, a skilful 
operator may be able to secure the bleeding vessels through 
the vaginal incision. Indeed, it has been advocated that the 
ruptured tube should be brought down, the surfaces cleansed, 
and sutures so introduced as to control the bleeding vessel 
and close the opening, leaving the tube in place. Such a plan 



ECTOPIC GESTATION. 563 

of procedure, however, is inadvisable. The fact that the cahber 
of the tube is so obstructed as to have caused an ectopic preg- 
nancy would indicate that its retention must necessarily subject 
the patient to the danger of a recurrence of the condition. The 
abdomen opened, the bleeding vessel secured, with aseptic pre- 
cautions, no great effort need be made to free the peritoneal 
cavity of blood, for, if the patient is kept under proper regimen, 
the blood is quickly reabsorbed and serves in some degree to 
sustain and support her. The absolute indication at this stage 
is to arrest the hemorrhage, and this is most effectively accom- 
plished through an abdominal incision. As soon as the abdominal 
incision is made there will be a gush of blood. The pelvis 
will be found more or less occupied with blood-clot ; do not stop 
to turn out the clots, but proceed through the clotted blood 
to the fundus of the uterus and along either tube to discover 
the sac. The site of the gestation is recognized as a soft, bogg}^ 
enlargement of varying size and consistency, according to 
whether the ovum is, or is not, in situ. The sac is brought up 
and examined for the rent. When the hemorrhage is marked, 
the pedicle is at once secured with pedicle forceps until the 
cavity can be cleansed and ligatures applied. After ligation 
the sac is cut away. If the patient is very profoundly anemic, 
no time should be lost by attending to the toilet of the abdo- 
men, but it should be simply irrigated with normal salt solution 
to carry away the principal clots. 

3. The treatment of the patient subsequent to rupture, (a) 
with intraperitoneal hemorrhage. The patient, having rallied 
from the shock, will in very many cases recover without opera- 
tive interference by keeping her perfectly quiet, promoting 
drainage through the intestinal canal by frequent purgation, 
and limiting the amount of food and drink that is given. She 
is thus obliged to live upon her tissues, which will promote the 
absorption of even a large collection. As we haA'e already 
seen, the tube which has been the seat of an abortion will gener- 
ally be found distended with clots, and the same material will 
fill up the retrouterine pouch. The convalescence of the patient 
will generally be enhanced by the removal of the tube and the 
clotted blood. This is particularly true when the tube is the 
seat of a perforation from the villi, for frightful hemorrhage 
may be found, and, besides, under such conditions it is likely 
to continue. Even when the hemorrhage arises as a result 
of rupture, we are not certain that the clot which plugs the 
vessels may not be loosened and a recurrence of bleeding follow. 
In spite of every precaution that may be obserA^ed it is not 
infrequently found that a collection of blood in the peritoneal 
cavity becomes infected from its proximity to the intestine. 



564 GYNECOLOGY. 

and thus a suppurative process is engendered, which prolongs 
the patient's convalescence. Even should this not occur, 
the blood-clot, becoming organized, gives rise to thickening, 
extensive adhesions, and more or less crippling of the function 
of the pelvic organs for the remainder of the patient's life. 
If the patient comes under observation some days subsequent 
to the evident rupture, thus affording sufficient time for the 
vessels to become occluded by clots, and with an accumulation 
of blood in the pelvis, which frequently is walled off by plastic 
exudate from the general peritoneal cavity, the preferable 
plan of procedure would be to make a free incision into the 
vault of the vagina. Two fingers should then be introduced 
through this opening, the clots broken up and evacuated, the 
cavity thoroughly irrigated with normal salt solution and 
packed with iodoform gauze. The tube may frequently be 
brought down and secured by ligature or clamp between the 
seat of rupture and the uterus, and the mass be thus removed. 
This is particularly true when the tube is occupied by a large 
blood-clot. When the tube is situated high up in the side of 
the pelvis or the lower part of the abdomen, and in a position 
not readily accessible through the vagina, the abdominal incision 
is preferable, as it affords a better opportunity to inspect the 
condition of the pelvic organs, to remove the occluded tube, 
and, if necessary, the associated ovar}^ It has been urged 
that where one tube has been the seat of an ectopic gestation 
which has ruptured and led to operative interference, the other 
tube should likewise be removed in order to prevent the possible 
occurrence of an ectopic gestation within it. The many cases 
in which a normal intrauterine pregnancy has followed a tubal 
pregnancy would render such advice unwise. While numerous 
cases are recorded in which an operation for the removal of 
an ectopic gestation has been followed by the occurrence of 
gestation in the remaining tube, this, however, is not the rule, 
and it would be just as logical to forbid matrimony because an 
occasional marriage is unfortunate. 

(b) Extraperitoneal hemorrhage is a result of rupture of 
the tube between the folds of the broad ligament. A hemato- 
cele is thus produced which is situated in the cellular tissue 
between the layers of the peritoneum. The amount of hemor- 
rhage is necessarily limited by the size of the vessel opened, 
the blood pressure, and the distensibility of the structure into 
which the hemorrhage has occurred. Where the collection 
is small, it may be sufficient to treat the patient expectantly, 
watch her progress, and trust to nature to absorb the exudate. 
Even in this condition it should not be forgotten that in rare 
cases the embryo may survive the accident and continue to 



ECTOPIC GESTATION. 565 

grow. The continuation of the growth of the fetus presents 
additional and more serious problems. Prior to the fourth 
month the embryo, tube, ovary, and adjacent portion of the 
broad ligament, including the placenta, can generally be re- 
moved. Subsequent to this period, however, the placenta 
may have attained such a size as to render its removal difficult. 
Not infrequently the life of the patient is endangered by a 
subsequent rupture. The placenta extends upon the pelvic 
surface, covering over and surrounding the vessels, and the 
ureter. Moreover, the intestines may aid in forming the sac 
wall of the developing embryo and a condition result which 
would render any operative interference exceedingly serious. 
Where the patient shows marked symptoms of internal hemor- 
rhage and an examination reveals a collection of large size, 
an immediate operation is preferable, for the depressed con- 
dition of the patient increases the danger of infection of the 
effused blood from the walls of the adjacent intestine. When 
infection enters the sac, suppuration will follow. This, of 
course, greatly endangers the life of the patient. Early inter- 
ference with such a collection is preferably made through the 
abdomen, for the reason that it affords a better opportunity 
of exposing and securing the bleeding vessel. Having opened 
the abdomen, the peritoneal cavity so far as possible should 
be carefully walled off with a large quantity of gauze, the blood- 
clots evacuated, and the bleeding vessels searched for and 
secured. If the blood collection has been a large one and the 
pelvis is covered with adherent blood-clot, an opening should 
be made into the vagina, through which the end of a piece 
of gauze sufficient to fill the cavity should be carried. When 
the collection has been extraperitoneal, the abdomen can be 
walled off with gauze before the broad ligament is opened, 
the clots should be turned out, the bleeding vessel secured; the 
cavity packed with gauze, the end of which has been carried 
through an opening in the vagina, thus allowing the peritoneal 
wound to be closed. Care must be exercised, however, in this 
procedure not to injure the uterine artery or the ureter. 

4. The method of treatment advisable in advanced growth 
of the embryo, (a) the child alive. From the fourth month 
to the completion of pregnancy the existence of a quick placenta 
presents a condition which is generally regarded as the most 
dangerous in the whole realm of surgery. The sac has ruptured, 
the placenta has formed new and more extended attachments. 
While the condition of the patient can not be considered other- 
wise than grave, the immediate danger is not so great but that 
we can afford to wait until a later stage of the pregnancy for 
interference and thus give the fetus a chance for its life. The 



566 GYNECOLOGY. 

existence of the live placenta, and the profound hemorrhage 
which results from any effort at its removal, have led many oper- 
ators to question the advisability of any operative procedure while 
the child is alive. Some have advocated securing the death of 
the child by injecting into its body poisonous materials, such 
as morphin, or, when near the completion of the pregnancy, 
awaiting its death. They have justified this course of action 
by the assertion that in the great majority of cases the product 
of ectopic gestation is puny, ill developed, and often malformed, 
and that even when it survives extraction it usually lives but 
a few weeks, or at most months. Therefore they claim that 
the life of the mother should not be endangered to insure the 
life of a defective child. Experience, however, has disclosed 
that the extrauterine fetus may be well developed, and when 
it is evident that the mother can only be saved by operative 
procedure, it seems cowardice that this should not be employed 
at such a stage as will give the other being an opportunity 
for continued existence. Fortunately, the investigations of 
Dunning have demonstrated that the maternal chances are 
enhanced by operation during fetal life. The recognition 
of extrauterine pregnancy, then, should lead to the prepara- 
tion for operation at a certain definite time prior to the com- 
pletion of the gestation, preferably at about eight and one-half 
months. In resorting to operative procedure we must consider 
it from two additional standpoints: (i) As to the treatment of 
the sac; (2) the method of disposition of the placenta. The 
sac is composed of remnants of the expanded tube or of the 
broad ligament, thickened and in parts expanded. In some 
places coils of intestine or the adherent omentum also enter 
into its formation. The removal of the sac, consequently, 
is fraught with danger, not only to the adjacent large blood- 
vessels and ureters, but to the abdominal viscera in general. 
When the pregnancy has passed the fifth month with ample 
evidence of a living child, we would advise that interference 
be postponed until after the eighth month. It should be under- 
taken, however, not later than at eight and one-half months, 
in order to afford the fetus the best opportunity for its life. 
The operator is compelled to adapt his procedure to the con- 
dition immediately confronting him. The position of the 
fetus has been recognized and carefully outlined. In the major- 
ity of cases the median incision affords the best opportunity 
for the delivery of the fetus and the management of the sac 
and placenta. Having entered the peritoneal cavity, the 
sac is carefully examined and efforts made to avoid injuring 
the placenta. Where it is situated in front we should endeavor 
to open the sac on one side. After opening the sac the most 



i 



ECTOPIC GESTATION. 567 

available part of the fetus is seized and delivered quickly. The 
cord is clamped with two hemostats and cut between them. 
The fetus is then removed and given to an attendant to be 
cared for. We now come to the decision of the question we 
have already mentioned, namely, the management of. the sac 
and the disposition of the placenta: (i) The sac, as already 
mentioned, is composed of remnants of the distended tube 
or the broad ligament, thickened and in parts expanded. In 
other places coils of intestine or portions of the adherent omen- 
tum assist in forming it. The removal of the sac, consequently, 
is fraught with great danger, not only to the adjacent large 
blood-vessels, but to the viscera and ureters. The preferable 
plan is to incise the sac, remove the fetus, and stitch the edges 
of the former to the abdominal wound. In well-advanced 
pregnancy we may possibly be able to push the peritoneum 
from the anterior abdominal wall and to penetrate the sac with- 
out opening the peritoneal cavity, but the chief difficulty would 
be to determine (2) how we shall manage the placenta. The 
method employed will entirely depend upon its situation. Its 
management is most promising when situated in the pelvis 
below the fetus. When above the fetus, the placenta may be 
injured and result in furious bleeding or, indeed, even death 
of the patient. Even prompt seizure and ligation of the uterine 
side of the sac may fail to arrest the bleeding. The abdominal 
aorta may then be compressed, the cavity packed with sponges, 
and an application made of perchlorid or persulphate of iron. 
The danger of bleeding has frequently induced surgeons to 
leave the placenta and allow it to slough away, employing 
proper measures for securing external drainage. When the 
removal of the placenta can be accomplished without too much 
risk, it should be done. In addition to avoiding the placenta 
in opening the fetal sac, we should exercise the precaution 
to prevent discharge of the amniotic contents into the peri- 
toneal cavity. After delivery of the fetus the operation is com- 
pleted in one of three ways: (i) The extirpation of the entire 
sac; (2) the removal of the placenta without the sac; (3) the 
retention of the placenta and the sac. 

1. Whenever it can be safely accomplished, the entire sac 
should be removed. By this method the operation is more 
complete and convalescence is more likely to be insured. This 
can be accomplished whenever we can construct a pedicle and 
the sac wall is made up of tissue that can without disadvantage 
be removed. The pedicle may be narrow or broad, as in an 
ovarian cyst. 

2. Extirpation of the Placenta with the Sac Remaining. — The 
placenta should be removed whenever it can be peeled out 



568 GYNECOLOGY. 

without hemorrhage, or when it is so situated that the vessels 
supplying it can be securely ligated and the mass removed, 
or when its position is such that effective control of hemor- 
rhage can be accomplished by tampons of iodoform gauze. 
After removal of the placenta the gauze may be removed and 
replaced by a large drain. 

3. The Retention of the Placenta and Sac. — When the pla- 
centa is firmly attached or it is evident that its detachment 
would result in dangerous hemorrhage, it should not be dis- 
turbed. The operator should exercise the greatest care in 
the management of the live placenta, as the hemorrhage in 
such cases is frightful and exceedingly difficult to control. 
Where the placenta is partially detached it may be necessary 
to proceed with its removal. This should be accomplished 
quickly, making firm pressure over the parts with iodoform 
gauze. If the attachment is of such a character as will permit, 
the parts should be quilted together by a ligature which is 
tied firmly around the base of the placenta. Where it is neces- 
sary to retain the placenta and the sac, one of the following 
methods can be practised : The sac can be fixed to the abdominal 
wall and the cavity drained, or the opening in the sac can be 
closed, covering over the placenta and shutting off the latter 
from the peritoneal cavity. In such cases the cord should 
be cut off close to the placenta, after previous ligation with 
chromic catgut, or the electro -angiotribe can be employed. 
This instrument appeals to me as an efficient means of con- 
trolling hemorrhage and insuring the removal of a portion 
of the placenta. To accomplish this, it will require a modifica- 
tion of the angiotribes at present in use, employing one with 
a more flattened surface, thus allowing a good portion of the 
placenta to be subjected to the slow action of heat. The pla- 
centa and sac should be closed and returned to the peritoneal 
cavity only when we have been able to secure absolute and 
rigorous antisepsis. The presence of a single microbe may 
lead to putrefaction of the placenta and suppuration. The 
disadvantages of the retention of the placenta are that its 
separation and discharge are tedious and present continuous 
risks of septicemia and peritonitis. Fecal fistula may form. 
These risks are decreased by irrigation of the sac, by the ligation 
of the cord close to the placenta without disturbing the latter, 
by carefully sponging the cavity, and then, as has been sug- 
gested, by hermetically closing it. Even though we are able 
to exclude the germs from the cavity, it must be remembered 
there is danger of their entrance through adhesions to the in- 
testines. Intestinal micro-organisms may gain access to the 
placenta and produce decomposition. The following rules have 



ECTOPIC GESTATION. 569 

been formulated by Sutton: (i) AVhen the placenta is situated 
above the fetus, attempt its removal; (2) if the placenta has 
become partially detached during the course of the operation, 
no choice is left but its removal; (3) the placenta below the 
fetus can be left; (4) if the placenta is left, the sac closed 
and subsequently symptoms of suppuration occur, the wound 
must be at once laid open and the placenta removed. 

(6) The Child Dead, Mummified, or Reduced to a Lithopedion. 
— The death of the child at any stage results in very early arrest 
of the circulation in the placenta. The continuation of the 
growth of the placenta after the death of the fetus has been 
considered as a possibility, but this is very improbable. The 
placenta does not decompose, but undergoes slow and complete 
atrophy. The vessels in the maternal portion atrophy and dis- 
appear. This, consequently, leaves much less of the placental 
structure than would be found in an extrauterine pregnancy. 
The absorption of the placenta continues until, in those cases 
in which the lithopedion is formed, the placenta is found to 
be entirely absent. Should the patient come under observation 
when the history would lead us to suspect that the fetus has 
but recently perished, it would be wise to postpone operation 
a few weeks later, when arrest of the circulation in the pla- 
centa may become complete. The sac is exposed by the ab- 
dominal incision, the general peritoneal cavity is well pro- 
tected by gauze packing and care exercised that the contents 
of the sac shall be removed without soiling the peritoneum. 
The escape of the contents into the peritoneal cavity should 
be prevented by the employment of an aspirator and the en- 
vironments of the sac should be carefully guarded with sponge 
packing before it is opened. The fetus is withdrawn and the 
sac then examined, with a view to its removal, if possible. 
Where the condition will admit, the entire sac, with the enclosed 
placenta, should be removed. If knuckles of intestines are 
adherent to the sac, the greatest care should be exercised in 
their separation, in order to avoid inflicting injury to them. 
Where the adhesion is very firm, the separation should be made 
at the expense of the sac wall, leaving a portion of it attached 
to the intestine. When a large portion of the intestine enters 
into the formation of the sac wall, the removal of the sac will 
not be feasible. In such cases the placenta should be peeled 
out, the cavity thoroughly sponged with carbolic acid and 
afterward with alcohol, dried, packed with gauze, and its edges 
stitched to the abdominal wound. Where the sac is dependent 
and in close approximation to the Douglas' pouch, an opening 
should be made through its base into the vagina, through which 
drainage may be effected and the upper part of the sac closed. 



570 GYNECOLOGY. 

The vaginal drainage of the sac should be employed whenever 
possible, as the drainage is from the most dependent portion 
and the convalescence of the patient is much shorter and 
the dangers of subsequent ventral hernia greatly decreased. 
Following the death of the fetus marked changes occur. 
The fetus itself may become mummified, its watery portions 
absorbed, forming a flattened mass. Or, again, the entire 
fetus undergoes a substitution of fat for its original structures, 
forming a lardaceous condition; or, again, we may have the 
fetus and its sac filled up with calcareous deposit, causing a 
rather dense, hardened mass. Some of these conditions may 
continue for years. A lithopedion has been found in a woman 
of ninety. Their presence, however, always predisposes to 
infection, which may result in suppuration, with subsequent 
discharge of particles of the calcified mass. Wherever pos- 
sible, the entire mass should be removed. Wherever it is rec- 
ognized, after an abdominal incision, that the mass has formed 
extensive adhesions to the intestines and other structures 
of such a character as to preclude the probability of successful 
removal, the sac should be opened, its contents so far as pos- 
sible removed, the sac wall stitched closely to the abdominal 
wound and its cavity packed with gauze. The removal of 
the fetus and the drainage of the sac result in its complete 
obliteration and the restoration of the patient to health. 

(c) Following Decomposition of the Fetus and Suppuration 
of the Sac. — Decomposition of the fetus and suppuration of 
the sac are indicated by symptoms of inflammation, the sac 
becoming tender to pressure with evidence of localized peri- 
tonitis. The temperature of the patient will be elevated, pos- 
sibly recurring chills, night sweats, progressive emaciation, 
and symptoms of low continued fever will be manifest. Lique- 
faction of the sac by pus formation causes thinning and even 
rupture of its walls, with the escape of its contents into the 
peritoneal cavity, the bladder, the intestine, the vagina, or 
through the abdominal walls. The rupture results in the for- 
mation of a sinus, through which often will be found passing 
fragments of small fetal bones. The existence of suppuration 
should be considered an indication for immediate operation. 
To open the sac without entering the peritoneal cavity is, of 
course, more satisfactory, and this occasionally can be accom- 
plished. If the adhesions between the peritoneal surfaces are 
not extensive, the opening may be a small one, and by gauze 
packing and other means the adhesions may be extended. 
Where parietal adhesions do not occur, the sac should be opened 
and its contents thoroughly evacuated, but the peritoneal 
cavity must be thoroughly protected from soiling by gauze 



GENITAL TUMORS. 571 

packing. Every fragment of bone should be removed, for 
otherwise the obHteration of the sac will not take place and 
suppuration will continue as long as the irritation remains. 
In the convalescence the cavity of the sac should be thoroughly 
packed with iodoform gauze and the sac itself be stitched to 
the skin edges. During the convalescence the cavity should 
be frequently irrigated with antiseptic fluids. We may some- 
times be able, especially where the opening has taken place 
through the abdominal wall, to dilate the sinus and empty 
the sac without opening into the general peritoneal cavity. 
This method of procedure can be effectually employed in the 
opening through the abdominal wall and the vagina, but open- 
ings into the bladder or intestine will require abdominal opera- 
tion. However, efforts should be made to remove the sac, 
if possible, and to close the intestinal or vesical openings. 

GENITAL TUMORS. 

486. Definition. — A tumor of the genito-urinary tract is 
a distinct swelling or protuberance which may develop upon 
or within any portion of either the genital or urinary structure. 

Any inflammatory swelling is a tumor, but the term is 
here confined to such swellings as are circumscribed and can 
be more or less definitely differentiated, have a marked course, 
and are rarely associated with febrile symptoms. The division 
of these tumors into two great classes, the benign and malig- 
nant, is of classic origin, and the clinical importance of such a 
classification of growths of the genitalia is equal to that in any 
other portion of the body. 

A benign tmnor is one in which the course of development 
is local, the progress not destructive to life, and no tendency 
to recur exists after its removal. 

The malignant tumor, on the contrary, in its march of in- 
vasion, little by little infects the entire organism, and shows 
a marked tendency to relapse after surgical intervention. 

The study of the structure of growths shows a marked 
difference in the cellular tissue of the two classes, each having 
well-defined tissue changes, which render them recognizable, 
and from which the future progress may be predicated. 

In the differential diagnosis it is often difficult to draw the 
line where the benign terminates and the malignant begins. 

In some of the uterine and ovarian growths, particularly 
of the glandular varieties, we are forced to rely upon the subse- 
quent progress for the determination of the proper classifica- 
tion. Notable examples are the glandular and malignant 
adenomas of the uterus and the papillomas of the ovary. 



572 



GYNECOLOGY. 



In the consideration of the subject we will, for more ready 
comparison, study separately the tumors, benign and malig- 
nant, of each portion of the tract. 



VULVA, VAGINA, AND BLADDER. 



487. — The tumors of the vulva and vagina may be divided 
into cystic and solid. The cysts may contain either gas or 
liquid. All varieties of tumors are comparatively rare both 
in the vulva and the vagina. 




Fig. 43 1. ^Anterior Labial or Inguinal Hernia. 



488. The gaseous cysts are hernias which present in the 
vulva in two varieties, the anterior labial or inguinal, and the 
posterior labial. The anterior labial hernia is analogous to 
the scrotal hernia in the male. It is formed by a portion of 
intestine or omentum descending through the inguinal canal 
and distending the large labium (Fig. 431). This form of 



GENITAL TUMORS. 



573 



hernia is comparatively rare in women. Femoral hernia is 
much more frequent in the female. In the latter the hernial 
sac emerges below Poupart's ligament and makes its exit as 
a lump in the groin, which, as it increases in size, pushes up 
over the ligament. In the sac of an inguinal hernia has been 
found an ovary and tube and even the fundus of the uterus. 
Instances have been recorded of an ovarian cyst or a tubal 
gestation complicating such a hernia. The posterior labial 




Fig. 432. — Posterior Labial Hernia. 



hernia (Fig. 432) is formed by the intestine driving the perito- 
neum through the pelvic aponeurosis and the levator ani muscle. 
The sac appears at the side of or projects through the vulvar 
orifice. Labial hernia may sometimes be difficult to differentiate 
from hydrocele or a fatty tumor of the labium. A double 
hernia with an ovary in each labium associated with a large 
penis-like clitoris may cause some doubt as to the sex of the 



574 GYNECOLOGY. 

individual. In hydrocele a sensation of fluctuation is more 
distinct, the sac thin, the tumor quite translucent, and accom- 
panied by few, if any, distressing symptoms. The hydrocele, 
though evanescent when the canal of Nuck is open, is usually 
more continuously distended than is a hernia. A woman 
recently sent to me for diagnosis presented a tumor, the size 
of an orange, which occupied the left labium, was elastic, quite 
movable, and afforded a sensation of a hernia of the omentum. 
Careful investigation revealed that it was a lipoma of the labium 
and presented no indication of any thickening along the in- 
guinal canal, which would necessarily have been the case had 
the tumor been a hernia. 

The symptoms and treatment of hernia will be found in any 
surgical work. 

489. Liquid cysts naturally occur in a region so well pro- 
vided with glands as is the vulva. The retention cysts of the 
gland of Bartholin (Section 322), and hydrocele, a serous cyst 
formed by the gravitation of serum through the open canal 
of Nuck into the large labium, are the most important. Hydro- 
cele is analogous to the serous collection in the scrotum of the 
male. The sac is thin- walled, quite translucent, and affords 
a distinct sensation of fluctuation. 

When the canal of Nuck is patulous, the tumor can be made 
to disappear by elevation of the pelvis or under pressure. ' From 
hernia it is distinguished by the absence of any thickening 
along the inguinal canal; its translucent appearance; the pres- 
ence of fluctuation ; and the failure of the tumor to increase in 
size during coughing. 

Treatment. — The contents can be readily removed by punc- 
ture, but re-collect rapidly. Obliterative inflammation may 
be engendered after removal of the fluid by injecting some 
irritating agent and bringing it in contact with the entire cavity 
of the sac, but care must be exercised to prevent it being forced 
through an open canal into the peritoneal cavity. A more 
satisfactory procedure will be to make a free opening into the 
sac and pack it with iodoform gauze. 

490. Sebaceous cysts rarely attain to any size. They are 
found upon the labia majora, the labia minora, in the sulcus 
between them, about the clitoris, over the mons veneris, and 
sometimes upon the edge of the hymen. 

491. Blood cysts are occasionally found. These may origi- 
nate in a preexisting hematoma, through a hollow, round liga- 
ment (Koppe), in the sac of an old hernia, in the site of a throm- 
bus, or from dilatation of lymph- vessels. 

Cysts are also found in the hymen — Doderlein says, from 
fusion of adjoining surfaces; in the urethra, either from ob- 



GENITAL TUMORS. 



575 



literation of Skene's glandules or the dilatation of a terminal 
and unobliterated vestige of Gartner's duct. 

Hematoma of the vulva and vagina has been described. 
(Section 465.) 

Abscess. (Section 322.) 

492. Erectile or vascular tumors are rare in the labium, 
but when they occur, present characteristics similar to those 
in other portions of the body. Avascular growths about the 
urethra are much more 
frequent. Pozzi indicates 
that the hymen is not the 
simple isolated structure 
surrounding the vulva, but 
comprises, first, the mas- 
culine frsenum vestibuli ; 
second, the ring inclosing 
the urinary meatus; and, 
third, the hymen. The 
structure is the undevel- 
oped matrix tissue of the 
corpus spongiosum in the 
male, and has not become 
erectile. These considera- 
tions, he asserts, throw 
light upon the origin of 
some of the vascular 
growths of the urethra 
and meatus. The reten- 
tion of the erectile tissue 
in the female, Avhich is 
normal in the male, re- 
sults, through efforts at 
micturition, in the forma- 
tion and extrusion of a 
polypus, known as a ure- 
thral caruncle. 

A urethral caruncle ap- 
pears as a bright red, 

fragile looking projection from the urethral orifice. It is largely 
composed of dilated capillaries with a small amount of connec- 
tive tissue and is covered with pavement epithelium. In a 
recent study of some microscopic sections of these growths I 
discovered the presence of glandular structure quite well 
marked. The growth is amply supplied with nerves, which are 
more or less exposed. The structure of the gro^A^h accounts 
for its vascularity and great sensitiveness (Fig. 433). 



"% 


■^■1 


\ 


sik ^ 




Hi \ 


1 


Wj 




■\ 



Fig- 43. 



-Urethral Caruncle. 



576 



GYNECOLOGY. 



Etiology. — The growths may occur at any age. They are 
frequently seen in young children, are more frequently found 
in middle life, and have been seen in women as late as the seventy- 
fifth year. They occur with about equal frequency in the 
married and unmarried. 

Symptoms. — The growth usually projects from the urethral 
orifice and is generally situated upon the posterior wall. Sepa- 
rating widely, the vulva causes the tumor to be pushed for- 
ward and rendered more 
prominent. Its sensitiveness 
varies with different indi- 
viduals. In some it pro- 
duces no marked symptoms, 
while others complain of 
continuous burning, a sen- 
sation of fullness in the 
urethra, and marked pain 
during and for several min- 
utes following urination. 
Occasionally the distress is 
so marked that the act of 
micturition is prevented and 
the employment of a cathe- 
ter is rendered necessary. 
Its extreme sensitiveness fre- 
quently causes it to be a 
barrier to the sexual rela- 
tion, hence it is one of the 
causes of dyspareunia. 

Diagnosis. — The tumor is 
readily recognized by its 
bright red appearance, its 
extreme sensitiveness, and 
its fragility. A varicose 
condition of the urethral 
vessels may occur, but this 
is characterized by bluish 
projections from the ure- 
thral orifice, which are plainly recognized as distended veins, 
somewhat resembling hemorrhoids about the anus. A prolapse 
of the urethra may exist, but this condition forms a rounded 
projection which partly or completely encircles the urethral 
orifice (Fig. 434). 

Treatment. — The only treatment that affords any hope of 
success is excision. This may be done under cocain anesthesia, 
the mass picked up and cut off at its base with scissors, and 




Fig. 434. — Prolapsus Urethras. 



GENITAL TUMORS. 



577 



bleeding arrested by coaptating the surfaces with a sutui'e. 
It is much more satisfactorily accomplished, however, under 
general anesthesia, as the patient is then quiet and the manip- 
ulation can be more deliberate. The excision of the mass 
with scissors and the application of the thermocautery to the 
base are very efficient. In the employment of the thermo- 
cautery a wooden rod the size of a catheter should be pre- 
viously introduced to preserve the urethra from destruction. 
Especial care must be exercised to control the hemorrhage, 
as I have seen frightful bleeding occur from such an operation. 
493. Varicose Veins. — Varicose veins of the vulva are not 
infrequent during gestation. (Fig. 435.) Holden reports a 




Fig. 435. — Varicose Veins of the Vulva. — {Dr. W . Krusen.) 



case in which the labia majora were the size of a fetal head. 
The patient died of phlebitis. The tumor presents a bluish 
color on the surface of the integument, violet on the mucous 
surface, and gives rise to a sensation of weight in walking or 
when the patient is in the upright position. The rupture of 
such a tumor may cause serious or even fatal hemorrhage. 
The patient should be cautioned to w^ear her clothing loose, 
having no constriction about the waist, and the varicose parts 
should be supported. The most effective treatment is the 
excision of the principal veins. 

494. Neuroma of the vulva is a rare condition. Painful 

37 



578 GYNECOLOGY. 

nodules are occasionally recognized, and their presence oc- 
casions vaginismus. 

Treatment would be to excise the painful spots. 

495. Simple Vegetations. — Vegetations appear upon the vulva 
in the form of papillomata or condylomata, occasionally having 
the appearance of a cauliflower. They may be situated at 
the edge of the vulva in isolated projections, or may cover by 
a voluminous growth the whole surface of the external genitalia. 
The mass may extend backward around the anus, and may 
attain the size of a fetal head. The growth presents a pale 
red color, often a deep wine tint, and is situated upon the vulva, 
perineum, and margin of the anus, sometimes extending for- 
ward over the mons veneris and over the inner surface of the 
thighs. (Fig. 436.) A profuse leukorrheal discharge is gener- 
ally present, which is retained by these vegetations, and causes 
an extremely disagreeable and fetid odor. The decomposing 
discharges irritate the surface, which becomes greatly inflamed 
by walking and exercise, and are generally considered an in- 
dication of venereal infection, produced by either gonorrheal 
or syphilitic virus. Transmission of the disease has been ob- 
served by contact. The presence of vegetations, however, 
is not always an indication of specific infection, as these growths 
arise in pregnant women from a simple leukorrhea. The sur- 
face upon which they are implanted may become thickened 
by inflammation, undergo ulceration, and be covered by a glairy, 
fetid mucus which increases the resemblance to malignant 
disease. A vertical microscopic section, however, will reveal 
the true character. In the vegetations are dilated tree-like 
capillaries embedded in connective tissue, and covered with 
several layers of epithelium, thus presenting a marked con- 
trast to the nests or tubular masses of epithelium embedded 
in connective -tissue stroma, which indicate the presence of 
epithelioma. 

Treatment. — Keep the parts thoroughly clean, irrigate with 
bichlorid solution (i : 2000), and dust the surface with equal 
parts of alum and sugar or paint it with carbolic acid. When 
the vegetations are very extensive, the most effective method 
of treatment is to place the patient under an anesthetic and 
with scissors cut away the vegetations ; cauterize the base with 
nitric or chromic acid, or, still better, with the thermocautery, 
and subsequently keep the parts clean and dusted with drying 
powder. The convalescence will be rapid. When pregnancy 
exists, it need be no barrier to the method of treatment in- 
dicated, as the danger to the patient from sepsis following 
the delivery is much greater than any that could result from 
the treatment. 



GENITAL TUMORS. 



579 



The operation can be done after saturating the parts with 
a lo per cent, solution of cocain. Their removal by the curet 
has been advised, but the scissors affords a cleaner and more 




Fig. 436. — Vulvar Vegetations. 



■effective instrument. This method produces less irritation 
of the subjacent skin. The hemorrhage may be controlled by 
the application of a strong solution of persulphate of iron, but 



580 GYNECOLOGY. 

the thermocautery will prove more satisfactory. The burn- 
ing of the latter can be lessened by the application of a com- 
press wet with a 5 per cent, solution of carbolic acid. The ap- 
plication of a 10 to 40 per cent, solution of formaldehyde two 
or three times will cause the vegetations to slough, but this 
is a painful application. 

496. Edema.— Anasarca is frequently accompanied by ex- 
tensive swelling of the labia. The cause is readily recognized 
by the associated condition. When edema exists without gen- 
eral dropsy, it is indicative of some obstruction to the circula- 
tion in the pelvis. Edema confined to one labium is generally 
the result of injury or inflammation. A hard, dense exudation 
in one labium will usually be found to be due to a hard chancre, 
situated upon the same side at the margin of the vagina. 

497. Solid Tumors. — Elephantiasis. — Elephantiasis consists 
in chronic inflammation of the lymphatics, with dilatation of 
their canals. It is very rare in our climate, but is more likely 
to exist in hot climates. The cause of the condition is unknown. 
The affection consists of more or less considerable hypertrophy 
of the entire vulva, sometimes localized in certain regions, 
as, for example, in the clitoris. The large hypertrophied labia 
form voluminous masses, which may exceed the dimensions of 
of an adult head. (Fig. 437.) 

Three forms are described: first, the entire derma is hyper- 
trophied, with vast dilatation of the lymph-spaces; second, 
the engorgement of the lymph in the capillaries and large 
trunks; third, the lymphatic ganglia become the seat of fibrous 
alteration. 

Symptoms. — The enlargement is frequently so great that 
walking and urination are interfered with. Friction of the 
surface leads to ulceration, which is slow to heal. The thickened 
tissues invade the vulva, and the perineal and anal regions, 
and form enormous tumors. When the surface of the skin is 
smooth, it is called glabrous; when roughened, with warty 
projections, verrucous; and papillomatous when the papillae 
are much hypertrophied. 

Diagnosis is easy. The hypertrophy and swelling of lupus 
are always accompanied by ulceration. The papillomatous 
vegetations are situated directly on the skin. In fibromata 
and myxomata which become pedunculated the tumors are 
isolated and circumscribed, while elephantiasis is diffuse. The 
cause of the condition is unknown, although it has been at- 
tributed to syphilis. It is due to an acute lymphangitis, with 
intense fever. The only effectual treatment is ablation and 
the suturing of the surface in order to secure union by first 
intention. 



GENITAL TUMORS. 581 

498. Fibroma and myxoma are tumors which are found in 
the large labia, though they may also develop in the nymphae 
or in the perineum. They are benign tumors of slow growth, 




Fig. 437. — Elephantiasis of the Vulva. 



though they occasionally attain to large size. The latter be- 
come pedunculated. The tumor may be enucleated or the 
pedicle may be cut without danger of hemorrhage. Figure 



582 



GYNECOLOGY. 



438 shows a fibroid tumor that occurred in the practice of Dr. 
S. E. Cox, of Nashville, to whom I am indebted for the illustra- 
tion. 

499. Lipoma. — A lipoma is a fatty tumor of the labium 
which may resemble elephantiasis. Lipomata are usually 
small, but Stiegel removed one that weighed ten pounds. 

500. An enchondroma is an exceedingly rare cartilaginous 
tumor which affects the clitoris. It may become as large as 
the fist and present calcified portions. Bartholin reports a 
Venice courtesan who wounded her paramour with her ossified 
clitoris. 

501. Malignant Disease of the Vulva. — Malignant disease 
occurs in the vulva in the form of epithelioma, sarcoma, and 
rarely as adenocarcinoma. Primary cancer of the vulva is 

rare. Epithelioma is the most fre- 
quent form and begins in the large 
labium or in the cleft between it 
and the lesser labium, less fre- 
quently in the clitoris or the 
meatus. The disease originates 
from the squamous epithelium 
and usually appears first as small 
warty nodules covered with thick 
layers of epithelium. Sometimes 
it follows irritation about the base 
of a pre-existing papilloma or wart. 
It is frequently preceded by psori- 
asis. The epithelium covering the 
nodules undergoes degenerative 
changes and causes a discharge 
of thin watery fluid mixed with 
blood. Groups of the embryonic 
cells fracture the limiting mem- 
brane and penetrate deeper tissues, supplanting the normal tissue 
and forming the characteristic epithehal pearls. Sometimes the 
cells will be found in the act of penetrating the walls of the 
blood-vessels, thus expediting the propagation of the disease. 
As the infiltration advances, superficial ulcerations occur, which 
gradually become deeper and involve the neighboring structures 
(Fig. 439). The inguinal glands are first sympathetically in- 
volved and later become infiltrated with the malignant cells. 
The disease occurs upon one side and then spreads to the oppo- 
site, possibly by inoculation through apposition. Adenocarci- 
noma results when the disease begins in the glands of Bartholin. 
Sarcoma occurs in the simple' form as the melanosarcoma. 
Symptoms. — The patient suffers from intense pruritus, in 




Fig. 438. — Fibroid of Labium. 



GENITAL TUMORS, 



583 



scratching for which the nodules, previously unnoticed, are 
discovered. These become excoriated and cause a bloody 
discharge and an exceedingly fetid odor; not infrequently the 
nodule resembles a wart which has become irritated at its base, 
and subsequently infiltrated. The nodules may be sessile or 
pedunculated, and subsequently coalesce. When the disease 
occurs about the urethra, the orifice may become contracted, 
and the canal may appear as a hard, indurated cylinder. The 




Fig. 439. — Cancer of the Vulva. 



ulceration presents excavated borders, with the adjacent skin 
infiltrated and hard, and the pubic hair may fall out. In the 
later stages the skin and tissues for some distance around the 
vulva become indurated and hard, and the glands of the groin 
are infected. With the extensive inflammation, the discharge, 
loss of blood, loss of rest, and the mental anxiety produce emacia- 
tion, and death follows from marasmus, sepsis, or metastatic 



584 



GYNECOLOGY. 



development. The latent period is a long one, the disease 
remaining for some length of time with but slight circumjacent 
or more extensive involvement. Death occurs in the second 
or third year. 

Diagnosis. — The history of continued genital psoriasis; in- 
tense pruritus, with small nodules; arrangement of the epithe- 
lial layer, which breaks down; the irregular ulceration, with 
infiltrated base and margins; and, later, glandular involvement. 




Fig. 440. — Appearance of the Vulva after an Operation for Cancer of the Vulva. 



are sufficient to indicate the character. Papillary vegetations 
extend over a considerable surface, are comparatively free 
from induration, and in no sense resemble cancer. A polyp 
or caruncle of the urethra has a base free from induration. 
Chancre is an indurated sore without disposition to spread, and 
is associated with glandular involvement, and later with the 
syphilitic eruption. Chancroid is a superficial ulceration without 



GENITAL TUMORS. 585 

induration. The adjoining surfaces readily become inoculated. 
The lymphatic glands promptly go on to suppuration and to 
the formation of buboes. In lupus the ulceration is serpiginous, 
with a tendency to cicatrization in the tissues first affected. 
Glandular involvement is rare. 

The prognosis of malignant disease of the vulva is bad. 
The cases usually come under observation after extensive 
involvement, generally after the lymphatic system is involved 
in the malignant process. Operative treatment delays the 
progress of disease and renders the patient more comfortable. 

Treatment. — The only hope for the patient consists in total 
removal of the disease. Some prefer the thermocautery or 
galvanocautery to the knife, as affording less danger from 
secondary inoculation. The scissors or the knife, however, 
are preferable, as by their use we shorten the convalescence 
and leave the structures less distorted. Care must be exercised, 
when possible, not to injure the meatus. In peri-urethral cancer, 
however, the sound should be introduced into the bladder, 
which \Y\\\ aid in the dissection, and the neoplasm, if neces- 
sary, should be followed to the neck of the bladder. In one 
case I removed the urethra up to the neck of the bladder without 
the patient suffering any incontinence. The incision should 
extend well around the disease, as far as possible invading 
healthy tissues. Bleeding vessels, rather frequent in this 
region, are secured with clamp forceps, and ligated if neces- 
sary with catgut suture, or the sutures closing the wound 
are so introduced as to constrict the bleeding vessels. Care 
must be exercised that the bleeding vessel does not retract and 
continue to bleed. The retraction thus of branches of the 
internal pudic caused hemorrhage which followed the pelvic 
muscles backward, broke through and formed a large hematoma 
upon the posterior surface of the sacrum, in one of my early 
operations for this condition. In such a case, if the vessel can 
not otherwise be secured, it will be better to tie the internal 
pudic over the external surface of the spine of the ischium. 
Fig. 436 illustrates the case of a woman who underwent opera- 
tion in which both labia and clitoris were removed, and the 
tissue subsequently united, as seen in Fig. 437. Any inguinal 
glands involved should be extirpated, as well as the principal 
chain of h^^mphatic vessels leading to them. The circumjacent 
fat and cellular tissue should also be removed. When the disease 
has progressed too far to render radical operation successful, 
the putrid discharge may be temporarily controlled by the use 
of the curet and cautery. When the disease is too far advanced 
for this, the surfaces may be kept sprinkled with iodoform and 



586 



GYNECOLOGY. 



pure charcoal, and dressed with gauze. The surface can be dusted 
with the following powder: 

B . Salicylic acid, gr. iv 

Boric acid, ^j 

Iodoform, ^[j 

Essence of eucalyptus, q. s. 

Kraske advises in extensive disease that the parts be thor- 
oughly curetted, the lacerated parts cleansed, and the surface cov- 
ered with flaps of healthy 
skin, as this procedure ren- 
ders the course of the dis- 
ease slower and the symp- 
toms less painful. 

VAGINA. 

Tumors originating in 
the structure of the vagina 
are infrequent. 

502. Cysts of the vagina 
are very rare. (Fig. 441.) 
They are found as isolated 
tumors in the mucous and 
submucous membrane, in 
the former usually directly 
beneath the squamous epi- 
thelium. Rarely more than 
two or three occur in any 
individual case; Schroder, 
however, removed six from 
one patient. They are more 
frequently found upon the 
anterior wall, and are ex- 
ceedingly rare upon the 
posterior. They vary in 
size from that of a pea to 
a hen's egg. The contents 
of these cysts are serous, 
more or less viscid or gummy, and are sometimes found mixed 
with blood. The epithelial lining of the sac may be either cyl- 
indric or laminated. The epithelium of some is ciliated (Abel). 
The origin of these growths is exceedingly difficult to determine. 
They have been attributed to the remains of Miiller's, Wolff's, 
and Gartner's ducts, to vaginal glands, or, according to Klebs, 
to dilated lymphatics. Neugebauer attributes most of them to 
remains of Gartner's canal. Hematoma of the vagina may serve 




Fig. 441. — Cysts of the Vagina. 



GENITAL TUMORS. 587 

as the origin for a cyst. Glands of the urethra may form reten- 
tion cysts, and, as they develop, may project into the vagina. 

The symptoms will depend upon the size of the cysts. Or- 
dinarily, they produce no inconvenience nor discomfort. Re- 
cently a patient underwent examination for some pelvic dis- 
order, when a cyst the size of a walnut was found upon the 
posterior wall. 

Diagnosis. — The condition may sometimes be mistaken for 
cystocele or urethrocele. The use of the catheter during the 
examination will demonstrate the thickness of the septum 
and the presence and size of the cyst. In the upper part of 
the vagina cysts are confounded with small tumors in Douglas' 
culdesac, such as prolapsed ovaries, a noncystic inflammatory 
condition of the tubes, and other inflammatory collections. A 
second vagina, which is closed and filled with retained secretion, 
may simulate a cyst. 

Treatment. — Only the large cysts require any treatment. 
The cyst may be opened and the sac cauterized most effectually 
with the actual cautery; or it may be packed with iodoform 
gauze, which affords drainage and sets up sufficient inflam- 
mation to obliterate the sac; or the entire sac may be enu- 
cleated. 

503. Fibroid Tumors and Polypi. — Fibroid tumors originat- 
ing in the vagina are very rare. They develop in the submu- 
cous or deeper layers of the mucosa and push into the vagina. 
As they increase in size they become polypoid, and hang by 
a pedicle. The structure is similar to that of uterine fibroids, 
and the growth is slow. The most common situation is the 
superior portion of the anterior wall. They are often adherent 
to the urethra, and distend the vulva. They are usually small, 
although they have been reported as weighing two and one- 
half pounds. Bandier and Gremlier report one weighing ten 
pounds. I am indebted to Dr. John C. DaCosta for the illustra- 
tion (Fig. 442) of a specimen which he removed from the vagina. 
As these growths increase in size, they become softened and 
ulcerate. They are much more likely to develop during the 
period of sexual activity, although Tratz reported one in a 
child of fifteen months which attained the size of a man's fist, 
and Martin one f of an inch long in a child two days old. 

Symptoms .—The symptoms of the growth are largely de- 
pendent upon its size. If small, the tumor may remain unrecog- 
nized. Larger growths cause dysuria and retention of urine. 
They project from the vulva, and the traction produces bleed- 
ing, ulceration, and erosion. 

Diagnosis. — The growths are readily determined by the 
situation, slow growth, and mechanical disturbance. The 



588 



GYNECOLOGY. 




softening, ulceration, and hemorrhage may sometimes lead 
to a diagnosis of malignant disease. 

Treatment. — The treatment consists in the removal of the 
growth by enucleation in sessile tumors, and by section of the 
pedicle in polypus. Hemorrhage is controlled by suture. 

504. Papillomata. — Papillary or warty growths are found 
in the vagina, generally in association with similar growths 
about the vulva. Generally they appear as small isolated 

projections over the walls, 
but occasionally the entire 
vagina will be filled. 

505. Malignant Neo- 
plasms. — In the vagina ma- 
lignant growths of primary 
origin are very rare. They 
most frequently extend from 
the uterus, rectum, vulva, 
urethra, or bladder, in one 
of three forms: first, papil- 
lary; second, infiltrated or 
nodular, both of which are 
included histologically under 
epithelioma; third, sarcoma, 
either diffuse or circum- 
scribed. They most fre- 
quently occur in the papil- 
lary form, although we may 
have carcinomatous infiltra- 
tion, either circumscribed, 
forming a broad-based ex- 
crescence, or a substitution 
of scirrhous for the normal 
tissue. 

Etiology. — Malignant dis- 
ease is most frequent during 
middle age, and is rare in 
youth, although I have seen one case of cancer of the vagina in a 
woman twenty years of age. Hegar once saw it in a woman in 
whom it was attributed to the irritation produced by a pessary. 
Epithelioma of the papillary form usually affects the posterior 
wall, as a broad-based excrescence which rapidly invades the 
culdesac and extends downward toward the vulva. Epithelioma 
of the nodular or infiltrated form appears as nodules, which be- 
come confluent, sometimes localized about the wall of the ure- 
thra. The ulceration advances rapidly, and may burrow into 
neighboring organs, producing rectovaginal or vesicovaginal 




Fig. 442. — Myoma of the Anterior Va 
inal Wall.— (J9r. John C. DaCosia.) 



GENITAL TUMORS. 



589 



fistula. The disease extends by the lymphatics to the pelvic 
cellular tissue; when it is situated in the anterior wall, the 
lymphatic glands of the groin are also involved. 

Symptoms. — Vaginal epithelioma very early causes hemor- 
rhage, which will be aggravated by locomotion, coition, and the 
various procedures in examination. There is a profuse purulent 
discharge which is exceedingly offensive ; pain is not so marked 
as in disease of the uterus, unless in the later stages. The 
principal symptoms 
are the mechanical 
obstruction to coi- 
tion and to delivery 
from stenosis, and 
the watery, bloody, 
and offensive puru- 
lent discharge. In 
a case recently un- 
der observation the 
disease had in- 
volved the anterior 
wall of the vagina, 
having apparently 
originated in the 
urethra, and formed 
a large scirrhus-like 
mass extending up- 
ward over one-half 
the anterior vaginal 
wall. The patient 
suffered from great 
inconvenience in 
urination, having 
frequent attacks of 
retention, and se- 
vere pain. 

Sarcoma. — Sar- 
coma occurs in two 
varieties: first, the 

diffuse sarcoma of the mucous membrane, often seen in young 
children; second, fibrosarcomatous growths, or melanotic sar- 
coma. Epithelioma, or cancer, may be distinguished from sar- 
coma by the use of the microscope. In the former, we note the 
characteristic assemblage of the epithelial cells, forming the 
pearly bodies, and preservation of the walls of the blood-vessels; 
while in the latter, the cells are more or less unconfined by 




Fig. 443. — Primary Cancer of the \"agina. 



590 GYNECOLOGY. 

connective -tissue stroma and the blood-vessels appear as mere 
sluiceways or blood-channels. 

Treatment. — The thin wall of the vagina is very slightly 
resistant to the progress of malignant disorder, and the dis- 
ease is rapidly carried by the lymphatic vessels to the deeper 
cellular tissue of the pelvis, so that by the time the patient 
affected with cancer or sarcoma comes under observation, very 
little can be done in the way of treatment beyond relieving her 
from the discomfort produced by the accompanying symptoms. 
Complete recovery is rare. Eiselsberg, in a case of cancer which 
involved the whole of the rectovaginal septum, resected the 
coccyx and established an artificial anus in the sacral region 
after extirpating the whole of the diseased part. The patient 
rapidly recovered, and had control of her stools. In a patient 
of mine, when the disease had proceeded from the rectum, 
involved the posterior wall of the vagina and the perineum, 
and extended close to the cervix, I removed the coccyx, re- 
sected the sacrum, excised six inches of the rectum, removed 
the ovaries, tubes, entire posterior wall of the vagina, and 
the posterior commissure of the perineum. The rectum was 
stitched to the sacrum posteriorly, and to the anterior wall 
of the vagina anteriorly, the peritoneum having been pre- 
viously closed. (See Fig. 498.) A colostomy had been per- 
formed upon the patient before she came under my obser- 
vation. After the patient had recovered from the pelvic opera- 
tion the opening in the intestine was dissected out and the 
two ends of the bowel were reunited. The patient was under 
observation for nearly thirteen months. The contraction of 
the intestine at the site of the former colostomy was sufficient 
to give the patient warning of the passage over it of feces, so 
that she could prepare herself for the evacuation of her bowels 
and avoid soiling her clothing. 

506. Tumors of the Bladder. — Benign new growths of the 
bladder are claimed to be very rare in the female; the most 
frequent are the villous polypi, called by Rokitansky villous 
cancer. Albarran declared that every tumor of the bladder 
was malignant. The frequent deaths from uncontrollable hemor- 
rhage and relapse would seem to justify such a diagnosis, but 
after careful microscopic investigation of the anatomic structure 
of the tumor by Virchow, he asserted that it was not correct, 
and called the tumor fibropapilloma, or villous polypus. The 
growth is most frequently situated on the lower surface or over 
the trigonum, though occasionally found upon the fundus 
and in vesical diverticula. It is sometimes completely pedun- 
culated, so that several berry-like masses are situated upon 
a single stem, which is easily torn. In women these tumors 



GENITAL TUMORS. 591 

are more frequently pedunculated, while in men they have 
a broad base or present as multiple tumors. With water in 
the bladder they float about like a water plant. Sometimes 
there are several masses of various dimensions, like grapes 
or raspberries, upon a single pedicle. The tumors grow very 
slowly. These growths absorb water, and consequently be- 
come very much shriveled when kept in alcohol. Microscopic- 
ally, they consist of a thick portion, which ends in villi of thin 
connective-tissue frame and many large vessels. Vessels are 
often so well developed that they completely supplant the 
frame. The epithelium is then situated almost completely 
upon the vessels. In other cases the connective-tissue frame 
is thicker, so that one would incline to pronounce it a fibro- 
papilloma. The under layers of the epithelium are cylindric 
in form, while the superficial are polygonal and the epithelium 
sends in no processes. We do not find nests or alveoli in the 
connective tissue, so the characteristic structure of cancer 
is wanting. The base of the bladder-wall is thickened and 
infiltrated, a centimeter in thickness, which forms a crust dis- 
tinctly recognizable during operation. The tumor itself is firm 
or soft, according to the thickness of its stroma. The pedicle is fre- 
quently so soft that, in an operation, an attempt to tie it results in 
the thread cutting through or tearing it off. The large blood- 
vessels contained in the connective-tissue frame lead to engorge- 
ment, and not infrequently to strong venous hemorrhage. This 
is the principal symptom of the villous polypi. These polypoid 
multiple tumors may fill the entire bladder. They may even 
pass through the urethra to the external orifice. 

507. Mucous Polypi. — In cystitis not only enlarged papillae, 
but also mucous polypi, are observed. These growths have 
a smooth surface without papillomatous arrangement, and 
are poorly supplied with blood-vessels. Occasionally, they 
attain considerable size — from five to seven centimeters in 
diameter. 

508. Myoma. — A myomatous tumor of the female bladder 
is much more rare than in man. The tumors are hard, whitish 
upon the cut surface, arise from the vesical muscular struc- 
ture, and grow into the wall or become pedunculated. With 
the gradual thinning of the pedicle, the tumor loses vitality 
and becomes partly destroyed. 

Cystic or softened myomata are also recognized. 

Dermoid of the bladder has been observed (Thompson). 

Symptoms. — The most characteristic symptom is hemor- 
rhage. The bleeding is very likely to occur in the night, per- 
haps owing to congestion from being warmly covered in bed. 
Bleeding takes place without any other symptom, and must 



592 GYNECOLOGY. 

be carefully investigated, as the patient will frequently assert 
that it comes from the vagina. The hemorrhage may sud- 
denly cease, and the urine the following day be perfectly clear, 
to continue so for a number of weeks, when bleeding again 
recurs. After the tumor exists for some time, bleeding will 
become continuous. 

Pain may be absent for years. 

Cystitis does not necessarily exist. Indeed, small tumors 
may have no influence upon the mucous membrane; floating 
in the urine, they do not injure its epithelial surface. In spite 
of long-existing growths, we will find the bladder surface pale 
from the general anemia. 

When hemorrhage leads to the suspicion of the existence 
of vesical tumors, the use of the catheter must be practised 
with care. The touch of the instrument causes injury; por- 
tions of villous growths float into the eye of the catheter and 
are torn off. Such masses should be carefully examined. 
Tumors of the trigonum float into the internal urethral orifice 
and obstruct the flow of urine. In long-existing tumors the 
urine becomes progressively bloody, coffee-like, or brownish. 
The surface of the tumor, from which the blood arises, appears 
black, red, sometimes opaque, or a bright red. The continuous 
vesical hemorrhage leads to intense anemia, although it is sur- 
prising how long the patient will endure it. Gradual emacia- 
tion, and finally cachexia, appear. The disease may extend 
over a period of many years. 

Diagnosis. — Examination is practised by palpation with 
two fingers of one hand in the vagina, while the fingers of the 
other are placed over the abdomen. The patient lies upon a 
table or hard couch. If the bladder is emptied with a catheter, 
one must rem.ember its danger. The examination is made 
slowly, carefully, and systematically. Generally, the abdominal 
walls are easily depressed. When the patient is unable to 
relax them, an anesthetic should be given. By careful in- 
vestigation a tumor as small as a hazel-nut can be recognized, 
but pedunculated growths may easily be displaced to one side 
and elude the grasp, and leave one in doubt as to their presence. 
The ovaries are not unusually so situated that they may be 
felt, and lead to the belief that a vesical tumor is present. The 
cystoscope aids in clearing up doubt. Diagnosis should not 
be based alone upon palpation. The urine should be examined 
chemically and microscopically. Cylinder-like cells are char- 
acteristic of papilloma. The older writers placed great stress 
upon the character of the hemorrhage — whether fluid blood, 
worm-like clots from the ureters, blood only, in the first or 
last portion of urine, or pure blood followed catheterization. 



GENITAL TUMORS. 593 

These distinctions afforded differential diagnosis between renal 
and vesical hemorrhage, but are now considered of little value 
as compared with cystoscopy. By direct investigation the 
relation of the tumor to the vesical wall is observed, and bloody 
urine can be seen flowing from the orifice of a ureter. The 
bladder can also be investigated by touch with a finger intro- 
duced through the urethra, but this should be practised with 
the greatest prudence, and, preferably, with the little finger 
only, because overdilatation may result in incontinence. 

Treatment. — The one treatment for vesical tumors is opera- 
tive. Following the diagnosis, the operative procedure should 
be employed as soon as the condition of the patient will per- 
mit. High fever, suppuration, cystitis, and marked anemia 
are considered as contraindications. 

The removal of the growth is surprisingly easy. New loss 
of blood is endangered by every day's delay. Suppuration 
is not a contraindication. If the tumor is large, irrigation 
with the syringe does not secure disinfection, and suppuration 
ceases only after the complete removal of the mass, and thus 
the danger of nephritis is lessened. 

The tumors may be reached through the urethra by the 
urethral speculum. The masses are seized w^th forceps and 
torn off, cut through by the galvanocaustic loop, cut away 
with scissors or forceps, or scraped off with a sharp curet. The 
latter instrument, however, should be used only Avhen the 
finger can be introduced as a guide. Whatever method is em- 
ployed should be thorough. In large, broad-based, friable 
tumors much injury may be done by scraping or tearing. The 
bladder soon fills with blood, which is hard to remove and 
decomposes, and the necrotic masses often cause cystitis and 
suppuration. Syringing the bladder with ice-water and as- 
tringents is painful. 

If the pain, loss of blood, and cystitis are aggravated by 
the operation, it is hard to convince the patient that anything 
has been done for her relief. In extensive involvement or growths 
with a broad base the preliminary incision of the bladder is 
more effective and satisfactory, as by it the diseased structure 
and the field of operation are exposed to view and to more 
effective manipulation. 

Vaginal Incision. — As a guide a catheter is introduced into 
the bladder, upon which a longitudinal incision is made through 
the middle line of the vagina, about five centimeters long, of 
sufficient length to permit the introduction of two fingers. 
The incision can be enlarged with scissors or with a knife above 
and below, affording considerable exposure of the bladder and 
its morbid growths. 
38 



594 GYNECOLOGY. 

Bleeding vessels are secured by pressure forceps. The 
growths are then removed with forceps, scissors, knife, fingers, 
the galvanic loop, or the Paquelin cautery. In copious hemor- 
rhage syringe with either ice-water or quite hot water; cotton 
sponges wet with the latter may be pressed upon the bleeding 
surface. Sutures can not well be used, because they cut through. 
The precaution must be exercised to avoid injuring the ureters. 
Hemorrhage is very severe in these operations and greatly 
obscures the view. The fistula should be closed, a catheter 
introduced, and the vagina tamponed to compress the bladder 
and decrease the bleeding. An ice-bag should be applied over 
the lower abdomen. 

The trifling mobility of the bladder in the region of the 
trigone renders it difficult to expose a bleeding vessel through 
the vaginal incision, and the bleeding renders the field but 
little more accessible to view than through the dilated urethra, 
while through the latter the organ can be tamponed even more 
effectively than by the vaginal incision. 

Abdominal Incision. — The sovereign procedure is the high 
bladder incision. A transverse incision gives more room than 
a vertical, though the two may be combined in a T-shaped 
cut. The difficulty in securing firm union and prevention 
of ventral hernia subsequently, however, precludes its practice. 
The vertical incision requires strong traction to be made on 
each side. Fritsch prefers the transverse incision, claiming 
that recovery is excellent if the incision is not made too long — 
not over six or seven centimeters. The scar so disappears 
under the hair of the mons veneris that subsequently it is no 
more seen, even if the wound heals by secondary intention. 
It has the additional advantage that large vessels are not likely 
to be cut. He has seen a number of cases in which extensive 
hernia had formed above the symphysis, but these were cases 
in which the object of the operation had been castration, supra- 
pubic transverse section had been employed in the operation 
for .castration, or cases in which the Trendelenburg posture 
had been employed for operations upon bladder fistula. In 
all these cases the scar tissue could still be seen. In twelve 
of these cases the incision had been twelve or more centimeters 
long. Such an extensive incision is unnecessary in bladder 
operations. If the incision is made shorter, the recti recover, 
with a firm scar to the pubic bone. 

Fritsch describes the procedure as follows: The patient 
is placed in the Trendelenburg posture, with pelvis elevated, 
and the mons veneris and vagina are thoroughly cleansed. 
The bladder must also be thoroughly irrigated; the vagina, 
for the reason that the fingers may be required to be intro- 



GENITAL TUMORS. 595 

duced into it, in order to penetrate the bladder from above. 
The bladder should be irrigated with several liters of boric 
acid solution. It is better to employ a large quantity of water 
than a trifling quantity of disinfectant solution. If the urine 
is clear or the discharge of blood quite fresh, syringing is un- 
wise, as it can easily cause a hemorrhage. An assistant places 
his hands upon the abdomen in such a way as to keep the mov- 
able skin fixed, while a transverse incision is made above the 
symphysis. The point at which the incision is to be made 
should be fixed before the skin is put upon the stretch; other- 
wise upon drawing it up it may be found that the incision is 
too low. It should be made directly over the upper border 
of the symphysis. While one is operating in the loose fatty 
tissue behind the symphysis, an assistant pushes up the bladder 
with a thick male catheter. The projection made by the end 
of the catheter is readily seen, the tissue above it is picked 
up with a tenaculum, and the bladder-wall is cut transversely 
above the end of the catheter. As soon as the bladder is opened 
the margin on either side is seized with a pair of pressure for- 
ceps and the bladder is prudently drawn down so that the 
forceps will not tear. The catheter is removed and the incision 
extended right and left by scissors until a broad wound is made 
in the vertex of the bladder, which will permit one conve- 
niently to enter it with two fingers and inspect its inner wall. 
In this, as in all operations, it is important to proceed rapidly. 
The margin of the bladder is seized by ten or twelve pressure 
forceps, which hold the bladder open automatically and make 
its cavity visible. To sew the bladder to the margin of the 
wound would take more time. If the tumors are large and 
deeply situated, they may be discovered to the right or left 
by two fingers. The pedicle is seized between the fingers and 
the tumor prudently drawn up. As the structure tears easily, 
the bleeding point may sink back and vanish from view; when 
the bleeding is copious, one may be in doubt just what shall 
be done. It can be controlled promptly only through tam- 
ponade, which takes time; consequently, it is important, if 
possible, not to tear the tumor. 

Having fixed the situation of the tumor, one must make 
accessible the pedicle. This not infrequently may require 
an enlargement of the skin and bladder section. To avoid 
this, an assistant seeks to enter the vagina, and presses up- 
ward in the region of the pedicle. Hemorrhage may be con- 
trolled by a Paquelin thermocautery. The smallest points 
should be employed, in order to avoid extensive burning of 
the epithelium of the bladder. The ideal procedure is the 
employment of the galvanocautery. In small polypi and 



596 GYNECOLOGY. 

very small tumors the galvanocaustic loop does not act so well. 
To tie them off, is, of course, difficult, as the thread easily cuts 
through. Frequently the base can not be encircled, on account 
of the proximity of the ureters. If we pass a ligature deeply 
in the firm tissue, we may injure or occlude the ureter. A 
hot iron is not effective in arresting the bleeding, and yet this 
must be controlled in order to proceed. More favorable action 
is accomplished by long and continued direct compression 
of the wound from the vagina and bladder. A strong vaginal 
tampon has a good influence. Ice-water may be used with 
advantage, and influences the closed bladder still better. In 
the open bladder the influence is not direct on the bleeding 
vessels, as the bladder muscle, like that of the uterus or the 
placental part, contracts on the bleeding surfaces. When 
the pedicle is quite visible, so that with the Paquelin one can 
touch the proper place, we should employ the scissors to cut 
the growth away. The smooth, well-marked, cut surface can 
be compressed by the finger of the assistant, in the vagina, 
with a certain advantage. It may be necessary to tamponade 
both vagina and bladder and to apply a firm abdominal bandage. 
This method is effective in controlling hemorrhage. 

The means by which hemorrhage is to be controlled must 
be rapidly determined upon, whether it be the Paquelin, the 
application of a solution of iron, syringing with ice-water, or 
surrounding with needle clamp forceps. The tampon should 
be prepared beforehand, and should be ready. In large, broad- 
based, villous growths we should work with sharp curet and 
scissors. Hemorrhage is often quite considerable. If the 
tumor is situated in the trigonum, so that there is no danger 
of injury of the ureter, the base of the bladder- wall can be 
penetrated and ligated. The possible discharge of urine through 
stitch-holes is of no significance, for in Shucking' s operation 
for uterine fixation it is probable that the needle has frequently 
entered the peritoneal cavity, and it is only in rare cases that 
peritonitis appears. The necessity of preventing hemorrhage 
by a tampon after the operation excludes the possibility of 
complete suturing of the wound. We can, of course, draw 
together the bladder wound somewhat, as well as diminish 
that in the skin by lateral sutures, but in the middle it must 
be kept open for the eventual renewal of the tampon. In 
such cases it should be the rule to sew the bladder to the skin 
wound, in order to make its cavity accessible and to secure 
the tissue behind the bladder from overlying urine and wound 
secretion. As the patient recovers, the bladder suture cuts 
through, the organ sinks back, and the wound opening is gradu- 
ally closed by granulations. When the opening continues too 



GENITAL TUMORS. 597 

long, it should be narrowed by suture after artificial freshen- 
ing of the wound. A permanent catheter should be intro- 
duced, which is necessary in all bladder injuries. With an 
incision into the bladder vertex, or in bladder resection, do 
not completely close the bladder wound, but place a strip of 
iodoform gauze in the opening left in the wound. It has re- 
peatedly occurred that the patient accidentally or purposely 
has had the catheter removed, when the urine can flow from 
the wound without injury; but if the wound is entirely closed, 
the removal of the catheter would work injury to the processes 
of recovery. After the bladder tampon is removed hemor- 
rhage rarely occurs. Bloody urine disappears in from twenty- 
four to thirty-six hours after the removal of the tampon. While 
the catheter remains, the bladder should be irrigated with 
astringents or a weak solution of liquor alumini acetici. This 
direction applies also to the external wound, and the pledget 
should be wet with the same solution. The upper wound 
has a great tendency to close. If the granulations are weak, 
as in anemic patients, they can be stimulated by dilute alcohol, 
camphor, silver salts, or tincture of iodin. The appetite, which 
is lost through an excessive flow of blood from the tumor, im- 
proves, and the patient gains rapidly in weight. The patient 
should be permitted to rise from bed as soon as the wound 
is healed. When the operation is very late in the progress 
of the disease, the wound remains unaltered, the patient does 
not recover from the anemia, and does not regain her appetite. 
Whether the patient dies from loss of blood, from loss of strength, 
or by the influence of the operation, is difficult to determine. 

509. Carcinoma. — Klebs asserted that cancer of the bladder 
always began in the prostate. Had this assertion been correct, 
woman should be exempt from the disease. Primary cancer 
of the bladder has been described by a number of investigators. 
Bode alone has seen fourteen cases. Cancer appears as a harden- 
ing and thickening of the bladder-wall, which is covered with 
several layers of epithelium. Small tumors form in the per- 
iphery, sometimes as isolated masses, while complete infiltra- 
tion of the entire bladder is very rare. Following the destruc- 
tion of the epithelium, destructive ulceration of the cancer 
occurs. This takes on a malignant character if putrid germs 
appear in the bladder. 

Symptoms. — The urine smells like carrion; there is pain 
and vesical tenesmus. By rapid increase the carcinoma breaks 
through externally. High fever appears. The bladder with 
rapid growth of carcinoma is fixed in contraction in the para- 
vesical tissue. With the peritonitic irritation there is increased 
sensibility. The disease extends up to the ureters, and develops 



598 GYNECOLOGY. 

pyelitis on both sides, interstitial abscesses, or nephritis. If 
death has not already taken place, it occurs from high fever 
and profound cachexia. It is found that the ureters become 
dilated as a result of the pressure upon those portions situated 
within the bladder-wall. 

Uterine cancer simulates the symptoms of villous tumors. 
If infiltration of the bladder-wall takes place, symptoms of 
cystitis appear. It is sometimes asserted that after extirpa- 
tion of villous tumors carcinoma occurs in their place, but pathol- 
ogy does not seem to sustain this argument. The existence of 
malignant disease does not contraindicate operation, though 
it is necessary, in order to remove the matrix of the tumor, 
that a portion of the bladder-wall should be removed in order 
to operate in healthy tissue. In the adoption of this prin- 
ciple a portion of the bladder-wall, the trigonum, must be 
omitted. To remove it, we must remove the ureters, or at 
least the place at which they enter the bladder. Bardenheuer, 
in a case of extensive disease of the bladder, through an abdom- 
inal incision upon it, shoved back the peritoneum, loosened 
the bladder as far as possible from the perivascular tissue, 
raised it up, incised it longitudinally, secured it with sutures, 
and drew it into the abdominal wound. The now exactly 
determined tumor is, with an elliptic piece of the bladder-wall, 
excised, and the wound margins are united by continuous 
suture, sparing the mucous membrane. Finally, the belly wall 
is sutured and a continuous catheter introduced. Wassiljew 
reports. a case of total extirpation of the bladder for malignant 
tumor. The ureters were secured outside the bladder and 
sutured in the belly wall. The patient recovered, although 
both ureters became necrotic, in two centimeters of their course ; 
but the pyelonephritis improved, as well as the general con- 
dition. Bensa describes a case in which a greater portion 
of the bladder was extirpated on account of an infiltrated car- 
cinoma of the right bladder-wall in a woman fifty-one years 
old. The operation was accomplished by a median incision 
in the mons veneris; the symphysis pubis was separated and 
the bladder opened and loosened subperitoneally, except on 
the right side, where the peritoneum tore, but was immediately 
sutured again, then loosened on the left side; the left ureter 
was resected, and the under part of the right ureter, because 
it had been invaded by carcinoma. The ureters were replaced 
in the small remains of the bladder, which was closed by sutures. 
The symphysis was then closed with silver wire sutures and 
the wound tamponed above and below the symphysis. The 
patient died the day after the operation. Bensa holds total 
bladder extirpation as indicated, first, in benign tumors if 



GENITAL TUMORS. 599 

they are multiple and produce sufficient disturbance of the 
bladder function; second, in infiltrated malignant tumors if 
they occupy the greater part of the bladder-wall; third, in 
large, broad-based tumors of the base of the bladder. The 
entire bladder has also been resected for tuberculosis. How 
much advantage is to be obtained from these procedures is 
a question. Narrowing of the ureters in the artificial bladder 
and small abscesses from implantation and sutures cause dis- 
turbance for months, even though the case has been quoted 
in literature as a successful result. After extirpation of the 
bladder the ureters have been implanted in the vagina. While 
the vagina is normally aseptic, it is questionable how long 
it will so remain with this additional abnormal function. 



UTERUS. 

510. Fibromyomatous Tumors. — Myofibromata are benign 
growths which occur in the cervix as well as in the body of 
the uterus. Their structure consists of connective tissue, 
or of muscular combined with connective tissue. The former 
are indicated by the term fibroma; the latter as myoma or 
fibromyoma. The pure myomata consist only of muscular 
structure and exist only in the early stages. They usually 
appear singly and may attain rather a large size. 

The myomata are the most frequent form of uterine growths. 
Careful examination will disclose such a growth in 20 per cent, 
of all the women who have reached the age of thirty-five years 
(Bayle), in 40 per cent, of women of fifty years (Klob), but 
the great majority are small. The growth of the tumor is 
very slow; when rapid increase in volume is observed, it arises, 
not from an increase of tumor elements, but from a disturbed 
condition of tissue fluid, which will be considered later. The 
most favorable condition for rapid growth is an intimate vessel 
union with the uterus. 

It is the generally accepted view that fibroid growths in- 
crease in size only during the period of sexual activity, and 
remain stationary or undergo atrophy after the climacteric. 
It is quite probable that no myoma ever originates in the uterus 
prior to puberty or subsequent to the menopause. A tumor 
has been reported as having been found in the uterus of a girl 
aged ten years, but no opportunity was afforded to demon- 
strate the correctness of the diagnosis by microscopic inves- 
tigation. 

Sutton has reported a childless widow, who had never men- 
struated, as having carried such a tumor for ten years. Peter 
Muller and Joseph Taber Johnson both assert that the growth 



600 GYNECOLOGY. 

sometimes continues to increase after the cessation of men- 
struation. Hoffmeier says that such increase occurs in those 
myomata which stand in nutritive union with the peritoneum 
through organized bands of adhesion. The truth of this is 
especially indicated in omental adhesions, which greatly in- 
fluence the progress of the growth. He cites a woman in whom 
a thirty-five pound myoma, with numerous interstitial and 
omental adhesions, had continued to grow for a year after the 
menopause. 

A myoma is rarely found alone in the uterus. The dis- 
ease generally exists as a multiple tumor formation. Over 
fifty growths have been found in one uterus. J. Bland Sutton 
recently removed a uterus which contained one hundred and 
twenty myomatous growths, varying in size from a pea to an egg. 
They vary from a tumor the size of a pea to an enormous growth. 
Hunter removed, after death, a tumor that weighed 145 pounds, 
while the woman weighed but 95 pounds. 

How much the growth of myomata is influenced by the 
activity of the sexual organs remains difficult to determine, 
but the fact that myomata originate and have their greatest 
growth during the years most favorable for procreation can not 
be without significance. Myomata occur with about equal fre- 
quency in the married and unmarried. Observation does not 
justify us in the assertion that the size to which they attain or 
the rapidity of their growth is influenced by the married or the 
single state. Some regard sterility as a cause of myomata, 
others as a consequence. 

Winckel and Schroder consider that the following conclusions 
are justified: 

1 . Fibroid growths originate without relation to marriage or 
to pregnancy. 

2. Sexual excitement favors growth. 

3. The presence of a growth inclines to prevent child-bearing. 

4. Pregnancy promotes growth. 

511. Pathologic Anatomy.— Whatever the origin, they are 
found in either the body or the cervix of the uterus, but in 
larger proportion in the former situation, and more frequently 
in its posterior wall. 

The consistence of the growth varies with its structure. 
A soft muscular mass presents, upon section, a reddish-pink 
color, with wavy, glistening bands running in every direction, 
but with a tendency to form whorls about individual centers, 
owing to the origin of the disorder along the course of blood- 
vessels. The cut surface of a fresh section presents an uneven 
appearance, owing to the elasticity of the fibrous tissue, causing 
the softer muscle surfaces to bulge. The mass is enveloped 



GENITAL TUMORS. 601 

by a false capsule, produced by compression changes in the 
uterine structure. The capsule varies in thickness according 
to the site of its development. If the growth has originated 
in the middle layer, the capsule is thick and well formed; 
but if immediately beneath the peritoneum or the mucous 
membrane, the capsule will be very thin or may. even be 
absent. 

About the tumor is a layer of loose connective tissue, which 
permits ready enucleation. Occasionally, there are numerous 











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Fig. 444. — Microscopic Section; Myoma Uteri. — {Coplin.) 

fibrous bands to the capsule, which render enucleation difficult, 
and are so frequent as to appear like a hyperplasia. 

The tumor is surrounded by numerous large vessels, from 
which it is nourished, but which do not penetrate its substance 
to any great depth. 

The vascularity of the structure is slight as compared to 
that of the uterine wall, for well-formed vessels are rarely found 
away from the circumference. In the softer variety the blood- 
vessels are comparatively numerous; in the harder varieties 
they are very scant. 



yA:.L:.J.L.\j:^... .'Jj.-..^.v . :^...>. 



602 



GYNECOLOGY. 



512. Microscopic Appearance. — The comparative amount of 
muscular and connective tissues varies widely. In young 
and rapidly growing tumors the muscular tissue predominates 
and the capsule or line of demarcation between growth and 
uterus is ill defined. As the tumor becomes older and more 
mature, there is a substitution of connective for muscular 
tissue, and it becomes hard and dense. (Fig. 444.) The 
section differs in appearance according to its direction. A 
longitudinal section presents cells of an elongated shape with 
rod-like nuclei, while a transverse section resembles groups 
of round cells. Occasionally, between the muscle bundles 
are spores — lymph-glands lined with endothelium. They de- 
velop from cellular proliferation about the capillaries, and, with 

increase of connective 
tissue, may grow to 
large size. (Fig. 445.) 
513. Varieties. — 
Bishop follows Gus- 
serow's classification 
and divides myomata 
into the multiple and 
encapsulated and the 
single and nonencap- 
sulated. The former 
are found most largely 
in the body of the 
uterus, while the lat- 
ter grow from the cer- 
vix. This division is 
based upon structure. 
The multiple growths 
are hard and firm. 
They largely consist 
of fibrous tissue, ap- 
parently mature, and 
no longer continue to grow. They are also called fibromata. 
The single growth is soft and elastic. It is largely supplied 
with vessels and is rapid in growth. In its structures the mus- 
cular tissue will be found to predominate. They are known as 
liomyomata or fibromyomata. All myomata originate within 
the uterine wall, but upon their proximity to its inner or outer 
surface will depend their future progress. The most frequent 
classification, and that which we find most useful in practice, 
is a division of myomatous growths according to their situation 
into: (i) Submucous, intramural, or concentric (capsulated, non- 
capsulated) ; (2) interstitial, mural, or centric; (3) subperitoneal, 




Fig. 445. — Liomyoma of the Uterus. B. and L 
^ in. obj. ; i in. oc. 



GENITAL TUMORS. 



603 



extramural, or excentric (capsulated and noncapsulated) ; and (4) 
fibromyomata of the cervix. 

Degenerative changes which may occur in the life -history 
of such a growth are indicated by the terms: Edematous, Col- 
loid or Myxomatous, Fibrocystic, Calcific, Necrobiotic, Nec- 
rotic ; but these changes are not sufficiently constant to justify 
their employment to indicate a distinct classification. 

The same statement can also be applied to the further 



'-3 


L 


1 




u 





Fig. 446. — Submucous Myoma (Polypoid). 

division which is sometimes given: Sarcomatous, Adenomyo- 
matous, Telangiectatic, Lymphangiectatic. 

514. Submucous fibroids, according to the proximity of 
their origin to the mucous surface, present two varieties — the 
encapsulated and the noncapsulated or free. The former de- 
velop in the wall and are extruded beneath the mucous mem- 
brane by the uterine contractions. The second variety, the 



^^r. 



604 



GYNECOLOGY. 



free, originate immediately beneath the internal surface, and 
are not supplied with a capsule, but are closely enveloped by 
the mucosa. i\n encapsulated tumor may become free through 
absorption or thinning of its capsule from pressure. 

The encapsulated variety are much larger than the free. 
Nature regards such growths as foreign bodies and endeavors 
to extrude them from the uterine walls. Under this action 
a submucous fibroid may become pedunculated, when it is 
known as a submucous or fibroid polypus. (Fig. 446.) The 




Fig. 447. — Sessile Submucous Myoma. 



muscular capsule may resist expulsion and prevent peduncula- 
tion, while the tumor bulges into the uterine cavity from a 
more or less broad base, and is called a sessile submucous fi- 
broid. (Fig. 447.) 

The sessile and pedunculated submucous tumors enlarge 
the organ and increase its vascularity. (Fig. 448.) The re- 
peated contractions, together with the expulsive efforts, lead 
to hypertrophy of the muscle-wall to such a degree as to simu- 
late pregnancy. The circulation in the entire mucous mem- 



GENITAL TUMORS. 



605 



brane, and especially in that portion covering the tumor, be- 
comes obstructed, leading to severe hemorrhages. 

The severe pressure frequently causes atrophy and ulcera- 
tion in the free variety, and the production of grave secondary 
changes, such as sloughing and gangrene. Compression of 
the neck of a polypus may cause edema, and, when acute, can 
produce gangrene or sloughing of the mass, and a fatal termina- 
tion. In the slower form the chronic edema may often be 
mistaken for a cyst. Uterine contraction may lead to elongation 
of the pedicle of a pedunculated fibroid and cause its extrusion 
from the external os into the vagina, Avhere it can be readily 
recognized and removed. (Fig. 449-) The elongation of the 




Fig. 44S. — Submucous Myoma Occupying Utcrmc Cavity 



pedicle may become sufficient to permit the mass to hang from 
the vulva. The expulsion into the vagina may be sudden, 
but it generally occurs slowly. \^ery rapid expulsion of a tumor 
with a short pedicle may produce partial or complete inversion. 
Not infrequently the polypus may be felt projecting from the 
OS during menstruation, while it disappears during the intervals ; 
this condition is known as intermittent polypus. 

Rarely by the efforts of the uterus the tumor may be com- 
pletely and spontaneously separated and extruded. 

The pressure of the uterine or vaginal wall upon the tumor 
sometimes causes ulceration, from which adhesions may form 
and by which the nutrition is maintained. A polypus may be 



606 GYNECOLOGY. 

SO firmly gripped by the cervix as to cut off its supply of nu- 
trition and cause it to slough. The gangrene may spread up- 
ward and produce a fatal result. Such a condition can easily 
be mistaken for cancer. 

515. Interstitial, mural, or centric fibroid growths develop 
in the parenchyma of the uterus, frequently attain to enor- 
mous size, and involve the entire structure of the uterus, when 
they are then known as the diffuse or the gigantic fibroid. (Fig. 
450.) A second variety is the circumscribed general form 
(Fig. 451); the third, the local interstitial fibroid. (Fig. 452.) 
In the general circumscribed variety, as described by Schroder, 
the wall of the uterus may be filled by a large number of growths. 




Fig. 449. — Submucous Myoma Extruded into the Vagina. 

In the localized fibroma a single or two or three interstitial 
fibromata may be found. These growths are situated in the 
wall of the organ, surrounded by muscle-fibers and the loose 
connective-tissue capsule, from which they can be readily 
enucleated. In the diffuse form the entire structure of the 
uterus seems to be taken up by the growth, and it is difficult 
to fix a sharp border of limitation between the growth and 
the uterine wall. These growths, when they attain a large 
size, not infrequently draw out the lower portion of the uterus 
as a pedicle, which may be attenuated to the thickness of the 
finger, and twisted, as seen in one case by Kiister, where, in 



GENITAL TUMORS, 



607 



the twist, the torsion was two and one-hah' times. The cer- 
vical canal had been obliterated. Occasionally, the uterine 
body is found separated from the cervix. The muscular struc- 
ture of the uterus itself undergoes hypertrophy in these cases, 
particularly when but few growths occupy the wall. The 
uterine wall becomes thickened, its cavity is increased, and 
the cavity undergoes various changes in its shape and size, 
according to the development of the tumor and its projection 
into it. (Fig. 453.) The influence of the growth upon the 
endometrium is most marked. In a large interstitial myoma 
it may become strongly distended, not infrequently thin and 
atrophied. In other cases there is a hypertrophy of the entire 




Fig. 450. — Voluminous Myomata Occupying Anterior and Posterior Walls. 



mucous membrane, occasionally only of the glands; in others, 
the interstitial tissue between them is increased. Occasion- 
ally, the condition is complicated by malignant edema. In 
the great majority of cases hypertrophy of the mucous mem- 
brane is found associated with these growths. Indeed, the 
endometrium may be three or four times its normal thickness. 

516. Subperitoneal growths (also called subserous, excentric, 
or extramural) are generally spheric or ovoid masses springing 
from the external surface by a more or less distinctly marked 
pedicle. Like the submucous, these growths are sessile or 



i-tr J .-.-ti ".- xi- 'r. 



608 



GYNECOLOGY. 



pedunculated. While the latter class are polypi, that term 
is more generally applied to intra -uterine growths. 

The surface of the growth may be smooth or irregular, 
according to the contraction of the connective tissue. A division 
into free and encapsulated is made: the former covered by 
the serous layer, which is closely attached, without capsule, 
to the surface of the tumor; the latter, or encapsulated, are 
covered with a layer of muscle -wall beneath the peritoneum. 

The free are hard and only attain a small size; the encap- 
sulated are soft and often become enormous. The pedicle 
of the tumor varies in length and thickness. It may be short, 




Fig. 451. — Circumscribed Interstitial Myomata. 



thick, and permit but little movement between the tumor 
and the uterus, or long and attenuated, affording such marked 
freedom as to cause doubt whether the growth is connected 
with the uterus. The pedicle can sometimes become so twisted 
as to cut off the circulation of the tumor and lead to its loss 
of vitality, the development of gangrene, and subsequently to 
septicemia or peritonitis ; or the tumor, in more fortunate cases, 
may become adherent to the surrounding viscera and lose its 
association with the uterus. Such a growth is nourished by 
its adhesions. Not infrequently a very movable tumor causes 
ascites, and thus simulates a malignant growth. 



GENITAL TUMORS. 



609 



517. Fibromyoma of the Cervix. — Cervical myomata, like 
those of the uterine body, are submucous, interstitial, and sub- 
serous. These growths originate in the body of the organ, 
and, by the process of enucleation through contraction, may 
have been driven downward, either through the cervical canal 
or into its structure by splitting it externally or, as in the single 
noncapsulated tumor, had its origin in the cervix and grown 
either upward or downward. The latter may be either pedun- 
culated or sessile, and rarely attain a size larger than a goose- 
egg, although they may completely fill the pelvis. (Fig. 455.) 
They cause contraction and prolapse of the uterus, and simu- 




Fig. 452. — Local Interstitial Myomata. 

late inversion of the organ. They may be divided into two 
classes : 

(A) Those of the external os, in which the tumor is formed 
by a cylindric or elongated lip in the interstitial variety. (Fig. 
456.) The submucous growths of the cervical canal are oc- 
casionally polypoid, which, like slender stalactites, descend 
through the cervix by the splitting process. 

(B) Tumors from the sub vaginal portion. These are more 
important when developed from the external surface and situated 
between the layers of the pelvic floor. They become intra- 
ligamentary and exceedingly dangerous bv pressure upon the 

39 



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. - ' ^<".rlu ' <!• 



f«P 



610 



GYNECOLOGY. 



ureter or upon the pelvic vessels; also when posteriorly they 
press upon the rectum and push the uterus forward and up- 
ward. Occasionally, the tumor crowds anteriorly against the 
bladder, between it and the uterus. Most generally these 
tumors are found surrounded by a loose capsule, which permits 
of ready enucleation. Sometimes, however, there is no line 
of demarcation between the tumor and the uterine structure. 
518. Etiology. — These growths occur more frequently than 
any other to which women are subject. Not infrequently 
they may attain to considerable size without the patient being 
aware of their existence, and are then recognized only by ac- 




Fig. 453. — Uterus Opened, showing Multiple Interstitial Myomata. 



cident. The causes of their development are unknown. Reck- 
linghausen attributed their origin to embryonic tissue, the 
remains of the Wolffian bodies. The irritation which char- 
acterizes fibromata is not a physiologic irritation like that of 
pregnancy, but a diseased impetus. It is an unusual kind 
of local irritation, associated with a weak or debilitated con- 
dition of the concerned spot. This introduces Cohnheim's 
view of tumor origin, which was that the local irritation was 
brought to development by the presence of tumor germs. The 
influence of sexual irritation is appreciated, in that statistics 



GENITAL TUMORS. 



611 



demonstrate that in the majority of cases the first indications 
appear during the second half of the third decad: i. e., between 
the twentieth and thirtieth years. The tumor forms in the 
first half of the fourth decad, shortly after the thirtieth year. 
These gro\\1:hs rarely develop before or after these periods, 
although Biegel is reported to have seen one in a girl ten years 
of age, and Leopold the beginning of a myoma in a child. There 
has been much discussion as to the influence of the married or 
single state upon the development of these growths. The in- 
vestigations of i\l6ller show that 32.8 per cent, occur in virgins, 
67.2 per cent, in those who are not, but one -half of the latter 
are sterile. Hofmeier says that the number of births does 
not stand in any relation to the causal formation of the growth, 



Fig. 454. — Subserous Myomata. 

while Winckel believes that the married are more predisposed, 
and that the myomatous formation decreases the number of 
births. Shoemacher, on the contrary, asserted that the un- 
married are more frequently so diseased. Hofmeier accounts 
for the relatively large number of unmarried women who suffer 
from myomata by the explanation that the tumor formation 
is one of the few causes which lead them to consult the gyne- 
cologist. Prochownik gives syphilitic infection as a cause, 
but the growths occur so frequently in individuals in whom 
there has been no possibility of such infection as to render 
this view of little value. Olshausen and Gusserow assigned 
local irritation as the etiologic factor. Shoemacher also looks 



-^ff 



612 



GYNECOLOGY. 



Upon menstrual congestion as a cause, but to give these reasons 
for the development of the disease is equivalent to giving none, 
as it is necessary to seek further for the cause of the irritation. 
Moller, already referred to, frequently found that a myoma 
the size of a pin's head was separated from the uterine muscle 
by a distinct layer of connective tissue. Small arteries could 
be traced into the growths, which still retained their three 
coats ; consequently, he doubted the theory that myomata arise 
from the muscular coat of the blood-vessels. The cause is 
sometimes considered as congenital. The influence of heredity, 
as to whether there is a predisposition to the development 




Fig. 455. — Pedunculated Myoma of the Cervix. 



of such growths in families, may be questioned. Heredity 
seems to be manifested in the greater apparent and comparative 
susceptibility of the colored race to the development of fibroid 
growths. It is not unusual to find several members of one family 
suffering from myomata. Among the various causes it is 
probable that sexual irritation should have the first place, 
and this irritation may have been engendered without the 
uterus having undergone the changes incident to pregnancy 
and labor. The abnormal irritation may be the result of mas- 
turbation, of psychic disturbances, of such unnatural processes 



GENITAL TUMORS. 



613 



as the evasion of maternity, of the psychic phenomena engen- 
dered by body-contact with man, of sexual agitation, and 
of other factors which may produce repeated injurious influence. 
It is quite possible that defective development or an abnormal 
position of the uterus may exert a marked influence in the 
development of these growths. Mann reports a childless widow 
at the age of forty-three, twice married, w^ho had never men- 
struated, and for ten years had had a large fibromyoma. It 
still remains evident, however, that in any individual myoma 
we can not positively assign a cause which can be considered 
a definite reason for its development. 




Fig. 456. — Sessile Myoma, of the Cervix. 

519. Symptoms. — The symptoms which lead us to suspect 
the existence of myomata are: Hemorrhage, pain, and abdom- 
inal cramp, especially when associated with progressive enlarge- 
ment of the abdomen. The symptoms of the individual case 
will depend largely upon the variety of tumor present. In 
the subperitoneal and in the interstitial, which have not en- 
croached upon the uterine mucous membrane, the growth 
may attain to considerable size without the manifestation 
of any symptoms which would attract the attention of the 
patient. Not infrequently, especially in the unmarried, such 
growths attain to a size so great as to be remarked by the friends 



.>•. -'U. -.-i^ !if< 



614 GYNECOLOGY. 

of the patient, before she is herself aware of its existence. The 
growth will be suspected when the patient has a history of a 
slow but progressive enlargement of the lower half of the ab- 
domen. Not infrequently, one of the first symptoms will be 
inability of the patient to properly evacuate her urine. In- 
deed, there may be even complete retention, which will re- 
quire the aid of the physician to secure relief, during which 
the presence of the tumor may be for the first time recognized. 
It may, in such a case, be situated in the pelvis, completely 
filling it and pushing the uterus above it. If the growth simply 
presses against the bladder, it may only slightly interfere with 
the evacuation, or, which is more likely, cause frequent mic- 
turition, because of the inability of the bladder to distend. 
Urination may be so painful and so frequent as to lead the 
patient and her physician to suppose that an inflammation 
of the bladder exists. Such a growth may press upon the 
rectum, causing constipation, retention of gas, tympanitic 
abdomen, interference with the circulation in the lower portion 
of the rectum, the occurrence of hemorrhoids, prolapse, marked 
anal pruritus, or burning of the anus, the existence of a fissure, 
and not infrequently the veins of the anus as well as those of 
the vulva become exceedingly varicose. Such a growth, be- 
coming incarcerated in the pelvis, may cause severe pressure 
on the surrounding structures with sloughing and gangrene 
of the pelvic soft parts. An intraligamentary tumor may push 
the uterus to the opposite side, and the organ may be so small 
compared with the tumor that its situation is with difficulty 
determined. (Fig. 458.) Pressure of the tumor on the pelvic 
nerves may produce pain extending down the posterior sur- 
face of the leg in the form of sciatica or a crural neuralgia over 
the front of the leg, or marked pain in the sacrum. While 
these symptoms may occur in any form of myoma, they are, 
however, characteristic of the subperitoneal and interstitial 
varieties, especially when the latter has not encroached upon 
the mucous membrane. In the interstitial growth, which 
grows toward the mucous membrane, giving rise to obstruction 
in its circulation and leading to engorgement and degeneration 
of the overlying mucosa, hemorrhage is a marked symptom. 
In the submucous varieties bleeding is a more or less constant 
and characteristic symptom. Hemorrhage may be manifested 
by an increase of the menstrual flow (menorrhagia) or an ir- 
regular bleeding (metrorrhagia) may result. Hemorrhage, as 
before stated, is a very prominent symptom of all submucous 
growths. The bleeding varies, and is not affected by the size 
of the growth, since a small polypoid growth will very frequently 
cause just as severe hemorrhage, — if not greater than that 



GENITAL TUMORS. 615 

which occurs from a large tumor. In these growths the menses 
become profuse and prolonged, resulting in marked anemia 
and great debility. The bleeding may be continuous and 
very free for a few days, then a period of brown secretion, to 
be again followed by profuse bleeding. Blood may be dis- 
charged as a bright fluid blood or in large clots. Clotting has 
no significance, and depends upon the size of the uterine cavity 
in which the accumulation occurs, or it may take place in the 
vagina; pedunculated polypi may be associated with severe 
flooding. Intermenstrual hemorrhage may alternate with 
periods of amenorrhea, which may continue for months, and 
when the patient is congratulating herself that she has recovered, 
another severe hemorrhage occurs. The bleeding occurs from 
two sources: (i) From the covering mucosa of the tumor; (2) 
from the general uterine surface. The former is the active 
primar}^ site of bleeding and is very vascular, particularly 
in the free variety. In some of the smaller growths the tumor 
will be found to be quite anemic. In these the hemorrhage 
is undoubtedly due to its irritation of the circumjacent uterine 
mucosa. Metrorrhagia from rupture of veins in the super- 
imposed mucosa is frequently associated with a profuse watery 
discharge, which adds to the depression and prevents the pa- 
tient from regaining her health. 

Leukorrhea, or discharge other than blood, is increased 
during the development of these growths. The extrusion of 
the gro^^^h into the uterine cavity increases the normal watery 
discharge from the uterine glands. The interference with the 
circulation and the consequent hypertrophy of the glandular 
tissue causes a profuse secretion. This may be truly glandular 
in character and mixed with the desquamated epithelium. 
Pus-cells and blood-cells may also be found, according to the 
degenerative processes, which sooner or later ensue. As the 
cervix becomes dilated, its glands add their thick viscid secre- 
tion to the abundant discharge. The partial or complete ex- 
trusion of the growth influences its circulation, not infrequently 
causing necrosis of portions of its surface or even the entire 
structure, according to the extent of the constriction. The 
discharge is often bloody, purulent, or watery, contains necrotic 
masses of detritus, and produces an extremely offensive odor. 
The patient, and not infrequently her attendant, has cause 
to suspect the existence of malignant disease. 

Pain is not a constant symptom. It is frequently more 
a sensation of weight or pressure in the pelvis and upon the 
surrounding organs. Intense pain may characterize very small 
growths, but is conditioned somewhat upon their situation. 
A growth pedunculated or so situated upon the uterine wall: 



■ ..4...yi...:.. 



616 



GYNECOLOGY. 



that it projects into the internal os may act as a ball-valve, 
and be the cause of the most agonizing labor-like pains. I 
have seen this form of dysmenorrhea in many cases. (Fig. 457.) 
In one patient it was so severe as to require the administration 
of two grains of morphin at each menstrual period to render 
it endurable. An operation subsequently revealed that the 
patient had a double vagina and a bicornate uterus with two 
distinct cervical canals in a common cervix. In one of these 
cavities was found a submucous tumor which, by a nipple- 
like projection, filled up the internal os, and explained the 
violence of the dysmenorrhea from which this patient had suf- 
fered. 

Sterility 'is a common symptom and conception is the ex- 




Fig. 457. — Bicornate Uterus. Both Cornua Containing Myomata. 



ception. The inflammatory changes consequent upon the pres- 
ence of the growth render it unfavorable for the reception 
and retention of the fecundated ovum. More frequently than 
is generally appreciated, the tubes have undergone secondary 
changes which result in the occlusion of their abdominal ex- 
tremities, and they are found to form retention cysts. Further- 
more, pathologic conditions of the ovaries are sometimes found, 
and this fact, also, is not given the consideration it merits. Con- 
stipation, hemorrhoids, anal fissure, prolapse, and pain arising 
from pressure upon the rectum are more or less constant symp- 
toms and signs. Vesical tenesmus, cysts, frequent micturition, 
retention of urine, dilated ureter, and hydronephrosis are pro- 
duced by disturbance and obstruction of the urinary organs. 



GENITAL TUMORS. 617 

Not infrequently the first symptom which leads to the discovery 
of the growth is the retention of urine, from pressure upon 
the vesical neck. The myomata may also be the cause of 
retention of urine from pressure upon the ureters, interfering 
with the entrance of the secretion into the bladder, and, as a 
consequence, we may have renal dilatation even to the extent 
of sacculation of the kidneys. In one of my early operations 
for myoma, upon a patient who had carried a large tumor for 
some twenty years, death occurred very shortly after the opera- 
tion. The autopsy revealed that both kidneys were distended, 
forming thin- walled sacs, that the ureters were several times their 
normal size, and that their walls had become greatly thinned. 
The protracted hemorrhages, profuse discharge, severe labor- 
like pain, and pressure upon the neighboring viscera, are prone 
to result in a profound anemia, which is characterized by a 
straw-colored appearance of the skin, often so marked as to 
simulate cachexia and plainly indicate the gravity of the pa- 
tient's condition. 

520. Diagnosis of Myomata. — The existence of a fibroid growth 
of the uterus may be suspected when there is a slow but progres- 
sive enlargement of the lower part of the abdomen. It may occur 
in either the single or married woman, and need not be associated 
with any special indication of ill health. The physician should 
have in mind the possibility of its existence in every patient 
who consults him regarding a sensation of weight or pressure 
in the pelvis, disturbance of urination, such as frequent mic- 
turition, difficulty in evacuating the urine, or even sudden 
attacks of severe retention, which may necessitate the use of a 
catheter. Indeed, in every such case the condition of the 
pelvic viscera should be examined preliminary or subsequent 
to the use of the instrument. Uterine growths should be still 
further suspected if the patient is complaining of hemorrhoids, 
fissure of the anus, frequent bleeding from the bowel, pain 
and distress during, and difficulty in, defecation. The surgeon 
should never be misled into subjecting a patient to operation 
or treatment for hemorrhoids until he has examined the con- 
dition of the uterus. Only recently I w^as asked to operate 
upon a Sister of Charity for severe hemorrhoids, when examina- 
tion of the pelvic cavity revealed a group of subperitoneal and 
interstitial fibroids, completely filling up the pelvis, the ex- 
istence of which she had never suspected. Profuse menstrual 
flow or irregular bloody discharge occurring in an unmarried 
woman or in one who does not give a history of the interruption 
of a recent pregnancy or abortion should lead to the suspicion 
of the existence of a submucous fibroid growth, particularly 
where this hemorrhage is associated with pain, often of labor- 



^ns" 



618 GYNECOLOGY. 

like character, as if the uterus were making an effort to expel 
a foreign body. This hemorrhage will often produce a marked 
anemia without emaciation, which distinguishes it from that 
associated with malignant disease. It should be remembered 
that no characteristic symptoms of myomata occur, and, there- 
fore, the physician is forced to rely for diagnosis and confirma- 
tion of his suspicions upon the physical signs. An important 
factor in this recognition is the consistence of the tumor or tumors 
in contrast with the surrounding soft structure of the unin- 
volved portions of the uterus, which permits the determination 
and delimitation of the growth. The alterations in the shape 
of the uterus, according to the situation of the tumor, are of 
interest. A good-sized growth may fill out the organ and 
give it a spherical shape. The further contraction of the uterus 
forces the mass into the cervix, where it may distend the en- 
tire organ and be palpable at the external os. An intrauterine 
polypus is determined only by palpation through the cervical 
canal. If the os is sufficiently open, the pedunculation can be 
inferred by the mobility, and definitely determined by reaching 
the pedicle with the finger. In small fibroid growths with a 
long pedicle, the growth may be felt through the uterine walls 
to move under the pressure of the finger, even though the cervix 
is undilated. During the menstrual period with profuse menor- 
rhagia, the offending growth is frequently extruded or the 
cervical canal is sufficiently dilated to permit its recognition 
by the examining finger. A growth extruded during the flow 
is generally drawn back in the interval, and produces what 
is known as an intermittent polypus. A growth filling up the 
pelvis may make pressure upon the large vessels and so interfere 
with the return circulation of the lower extremities as to pro- 
duce enlargement of the superficial veins in compensation for 
the obstructed abdominal vessels. Pressure upon the ureters 
causes dilatation of these ducts, hydronephrosis, dilatation 
of the pelvis of the kidney, not infrequently a sacculation of 
the kidneys with destruction of the secreting tissue, the forma- 
tion of renal calculi, and even the occurrence of suppurative 
changes. These are characterized by more or less pain and 
discomfort in the region of the kidney, so much so as to possibly 
mask the pelvic lesion. Interference with the cardiac or renal 
functions causes profound anemia and the appearance of cach- 
exia, not infrequently interference with the veins of the lower 
extremities, phlegmasia, blocking of important vessels by 
particles of coagulated tissue, and possibly the formation of 
pulmonary and cerebral emboli. The diagnosis is determined 
by the bimanual examination, the introduction of one or two 
fingers into the vagina or the finger into the rectum, and the 



GENITAL TUMORS. 619 

other hand over the abdomen. In this way the uterus is care- 
fully palpated and any enlargement of its structure recognized. 
If such enlargement or hardening of the organ exists, its size, 
relation to the organ, and its resistance are carefully studied. 
The fibroid growth has a definite shape, is smooth in outline, 
is well defined, and has a characteristic resistance. It is im- 
portant in the study of such growths to arrive at a diagnosis 
not only as to the existence of fibroid, but also as to the character 
of gro\\^h which may be present. The decision, then, is made 
whether the gro\\i:h is an intrauterine or a submucous tumor. 
The endeavor is made to ascertain by palpating the cervix, 
when patulous, as to whether the growth is a sessile or polypoid 
tumor. If the uterus is occupied by interstitial groA^^hs, their 
situation is determined, whether they occupy the anterior or pos- 




Fig. 458. — Intraligamentary ^lyoma. 

terior wall or the fundus; if subperitoneal, from what portion 
of the organ they spring. The latter gro\\n:hs are divided into 
three types: (i) AYhen the growth proceeds from the fundus 
or the anterior wall, grows upward and in the progress of develop- 
ment becomes pedunculated ; (2) whether it is pushed out through 
the lateral wall of the uterus between the folds of the broad 
ligament, practically splitting and spreading this out and dis- 
placing the uterus to the opposite side (Fig. 458); (3) when it 
grows downward from the posterior wall and is beneath the 
peritoneum, but probably not even in contact with it. When 
the tumor is small and as yet nonpedunculated, it may be difficult 
to determine by conjoined manipulation from which wall it has 
originated. This can be accomplished either by the intro- 
duction of the sound into the uterus or, better, bv the dilatation 



U^^LJ- 



620 GYNECOLOGY. 

of the organ and the introduction of the finger. With one 
finger in the uterus and the hand over the abdomen or a finger 
in the rectum, the physician is enabled to accurately determine 
the relation of the growths to the uterine wall. The factor 
which should be fixed in mind as an essential one for the recog- 
nition of fibroid growths is their smooth, regular outline. In 
the fibromyomata of the vagina the tumor presents a mass which 
is situated in the vagina, not infrequently filling it, is quite 
movable, and between it and the vaginal walls the finger can 
be easily passed. Its situation external to the cervix pre- 
cludes the probability of it having undergone necrosis from 
pressure, but occasionally infiammation may be developed in 
the vagina from the pressure of the growth, which will lead to 
agglutination between the tumor surface and the vaginal wall. 
The attachment of the tumor is recognized by bimanual pal- 
pation with traction upon the tumor. 

521. Differential Diagnosis of Myomata. — An accurate diag- 
nosis of any condition is only secured by carefully reviewing 
the conditions with which it may be confused. The conditions 
with which myomata are likely to be confounded are: 

Normal pregnancy. 

Extrauterine pregnancy. 

Inversion. 

Carcinoma. 

Sarcoma. 

Incomplete abortion. 

Subinvolution with endometritis. 

Uterine displacements. 

Ovarian displacements. 

Ovarian cysts. 

Pelvic infiltrations. 

Sactosalpinx. 

Floating kidney. 

Normal Pregnancy, — The amenorrhea, subjective symptoms, 
regular growth of the uterus, absence of hardness in its walls 
and a sensation of elasticity are generally sufficient to determine 
the diagnosis of pregnancy. We have already seen that a 
limited amenorrhea may be characterized by a submucous 
myoma, and a patient may go for months without a hemor- 
rhage. On the other hand, hemorrhage may occasionally com- 
plicate the early months of pregnancy. I formerly attended 
a patient who always suspected herself pregnant if the menstrual 
fiow was especially free, and she continued to menstruate for 
two or three months following the occurrence of each preg- 
nancy. The myomata may be present as small, edematous, 
subperitoneal nodules, which may be mistaken for the extremities 



GENITAL TUMORS. 621 

of the fetus. Calcification of a fibroid has led to it being mis- 
taken for the fetal head. The presence of the tumor does not 
])reclude the possibility of pregnancy as a complication. The 
existence of pregnancy associated with fibroids should be sus- 
pected when the growth takes on more rapid enlargement, 
when the rapidity of the growth is greater than that which 
usually characterizes a fibroid tumor, and Avhen a portion of 
the mass presents a sensation of elasticity. The regular shape, 
size, and outline of the uterus under the bimanual, with the 
contractions of the pregnant organ, which are absent in the 
nonpregnant, contrasted w4th the more or less firm resistance, 
the irregular enlargement, and the smooth nodular outline, 
should establish the diagnosis. In diagnosis the following case 
very graphically illustrates, as shown in Figs. 462 and 463, that 
fibroid tumors under certain conditions may simulate pregnancy. 
The patient, about forty-two years of age, had applied to her 
physician because of an uncomfortable sensation attended 
with enlargement of the lower portion of the abdomen. On 
examination, he pronounced her pregnant. This diagnosis 
w^as repeated by him after a subsequent examination, and 
coincided in by other physicians. She came under my obser- 
vation some length of time after having completed the supposed 
normal period of her pregnancy and w^as referred to me as a 
case of delayed labor. Upon examination, the cervix presented 
its normal size. Above it, in front, how^ever, could be felt very 
distinctly two rounded masses with a sulcus between them, 
which was taken by the examiners to be a fontanelle. The 
abdomen was enlarged, about the size of a pregnancy at six 
months. There was a sensation of elasticity or rather of dis- 
tention in the abdomen. Making pressure against it, a mass 
could be felt which pushed back on deep pressure, and it could 
be felt impinging against the abdominal wall when the hand 
was suddenly removed. This was taken to be ballottement 
of the fetal body. The bimanual examination, however, con- 
vinced me that if this was a pregnancy, it was extrauterine, 
as the mass could be felt too readily through the anterior vaginal 
wall to be within the uterine cavity. It was found that the 
woman continued to menstruate, that the enlargement had 
increased only to a very slight extent in the last few months. 
The investigation of the condition caused me to pronounce it 
one of multinodular myomata, which Avas a large mass with 
a rather thick pedicle, permitting it to be pushed away, but 
strong enough to bring it back against the abdominal wall, 
and thus produce the sensation of ballottement. The freedom 
of moA'ement was accounted for by the presence of free fluid 
in the peritoneal cavity. This diagnosis was confirmed by 
operation. 



I' - j< imt^vjEi*momm 



■T?^ 



622 GYNECOLOGY. 

Extrauterine pregnancy will present symptoms in the early- 
stage similar to those of a normal pregnancy, as amenorrhea, 
nausea, mammary changes, etc., associated with a history of 
colic-like pains on one or the other side of the pelvis, with later 
a marked tearing pain, possibly attended by fainting, and symp- 
toms of internal hemorrhage. Subsequently a mass will be 
found in the side or an increase in the size of the abdomen will 
take place, but this enlargement will be less symmetrical than 
is the case in a normal pregnancy. The examination of the 
patient will ordinarily reveal the uterus slightly enlarged, some- 
what softened, free from any irregular or nodular masses, pos- 
sibly displaced to one side, or crowded forward by a mass which 
is situated in the side of the pelvis or in Douglas' pouch pos- 
terior to the uterus. In the advanced stages the parts of the 
fetus may be felt, probably with greater ease than if the fetus 
was contained within the uterus. 

Inversion. — Inversion of the uterus may be associated with 
a myoma with a short pedicle, attached near to the uterine 
fundus. The efforts at extrusion of such a mass, after dilatation 
of the cervical canal, may cause a dragging upon the fundus 
and gradual inversion. A polypus with a moderately thick 
pedicle, when extruded from the os, may be distinguished from 
the body of an inverted uterus with difficulty. A myoma is 
said to be less sensitive than the uterus, but this is not sufficiently 
characteristic to be of much value in diagnosis. The inverted 
uterus shows upon inspection the orifice of the tube upon either 
side. In each condition the neck of the uterus can be felt 
encircling the pedicle of the tumor like a cuff. The diagnosis 
is best established by introducing a finger into the rectum, while 
traction is made upon the tumor. In case of inversion the 
cup-shaped cavity of the inverted uterus will be felt, where in 
ordinary cases the uterine fundus should be situated. The 
exercise of recto-abdominal touch, while traction is made upon 
the protruding mass, will afford an unfailing method of deter- 
mining the diagnosis. A sound passed into the uterus in a 
case of a cervical tumor will be found to pass at one side the 
entire length of the ordinary uterus. In an inversion of the 
organ the sound will pass an equal distance on all sides of the 
tumor. The diagnosis, ordinarily, however, can be accom- 
plished without the use of the sound. 

Carcinoma and Sarcoma.— Proinse bleeding, pain, and dis- 
charge are common to both fibroid tumors and malignant dis- 
eases of the uterus. In the majority of cases the offensive 
discharge associated with malignant disease is not found in 
myomata. The recognition of this fact has sometimes led 
to error in judgment ; thus, in a case where a myomatous growth 



GENITAL TUMORS. 623 

has pushed through the cervix, has been for a length of time 
constricted by it, caries or superficial necrosis follows as a re- 
sult of the interference with the circulation in the tumor, from 
which the careless observer may be led to a diagnosis of malignant 
disease. A digital examination of such a patient, however, 
reveals the fact that the vagina is occupied by a tumor which 
is firm in consistence, is smooth and regular in outline, is not 
friable nor easily broken down, and thus differs materially 
from the friable necrotic mass which is found in the vagina in 
the cauliflower growth of malignant disease. A sloughing 
fibroid within the uterine cavity may afford some difficulty 
in the diagnosis. It causes a thin, watery discharge, which 
is exceedingly offensive. It may have caused repeated attacks 
of hemorrhage. The associated loss of blood, with the absorp- 
tion of the products of decomposition from necrotic tissue, 
produce a condition of sapremia which is with difficulty differ- 
entiated from malignant disease. In such cases, however, 
the diagnosis is determined by dilatation of the uterine canal. 
The necrotic growth forms a large tumor, one which is more 
resistant, in which fragments broken away and examined pre- 
sent the regular lamellated structure of a fibroid growth, but 
nowhere is seen the nesting or collection of. epithelial masses 
surrounded by a connective-tissue stroma pathognomonic of 
carcinoma or the homogeneous mass of cellular tissue with 
an absence of true blood-vessels which characterizes the sarcoma. 

Uterine Displacements. — Flexions of the uterus are the 
varieties of uterine displacements most readily confounded 
with fibroid growths. Indeed, it should not be overlooked 
that a fibroid growth may be the cause of the displacement. 
The growth, by its smooth outline and situation, may form 
such an angle as to cause one to regard it as the fundus uteri. 
These are the cases in which the sound can be successfully 
employed to ascertain whether the direction of the uterine 
canal corresponds to the position of the tumor. The cases 
are rather few, however, in which the gynecologist can not 
accurately locate the fundus uteri and detect the relations of 
the growth thereto by practising the bimanual examination 
in association with the vagino-abdominal or recto-abdominal 
touch. Such an examination will reveal the greater consistence 
of the growth, its rounded, smooth outline, and the extent 
of its association with the uterus. In a flexion, when the organ 
is straightened between the internal and external fingers, the 
normal outline of the uterus is found restored. 

Displacements of the Ovary. — The ovary is likely to afford 
confusion of diagnosis only when it is firmly fixed to the uterus 
by inflammatory exudate or has become somewhat enlarged. 



l/^i^:>JJlr.lV ^#-. 



624 GYNECOLOGY. 

Its situation, the inability to recognize the ovary in any other 
situation, and its extreme sensitiveness should reveal its true 
character. 

Ovarian Cyst. — It is frequently difficult to determine the 
diagnosis between a fibroid tumor which has become edematous 
and has a long pedicle, and an ovarian cyst of the glandular 
or dermoid variety. If the cervix is grasped with a double 
tenaculum, while an assistant, with the hand over the abdomen, 
draws up the tumor, we are enabled through a rectal examination 
to ascertain a more exact determination of the relation of the 
pedicle of the tumor to the uterus. This examination, with 
the patient under the influence of an anesthetic, will generally 
be sufficient to determine the diagnosis. It should not be 
forgotten, however, that the existence of a fibroid tumor does 
not necessarily preclude the possibility of pregnancy, as we 
can have pregnancy complicating fibroid growths. I narrowly 
escaped operating some years ago upon a patient who had a 
history of having had a very profuse bleeding during the pre- 
ceding three weeks. The right side of the uterus presented a 
growth, which was firm and hard, and was recognized as a 
fibroid. Upon the left side of the abdomen there was more 
sensation of elasticity or indistinct fluctuation, and it was be- 
lieved that we had an areolar glandular ovarian growth closely 
adherent to a fibroid of the uterus. On the day set for the opera- 
tion, on starting to cleanse the vagina, a foot and leg of a fetus 
were found projecting from the dilated os, and a partly macerated 
fetus was delivered. Upon removal of the placenta the uterus 
contracted and disclosed a pretty good-sized fibroid upon the 
right side of the uterus. The patient recovered, and with 
marked decrease of the fibroid growth during the progress 
of involution, rendering operation for its removal unnecessary. 

Pelvic infiltrations are recognized by the previous history 
of inflammation and the irregular and undefined outline of 
the masses which are found. 

Sactosalpinx is usually preceded by a history of inflam- 
mation. The mass is felt at one side of, or posterior to, the 
uterus. When adherent to the latter, the connection is so 
irregular and undefined as to reveal its character. 

Floating kidney forms a tumor which is generally situated 
at a higher level. The fingers can be pushed between it and 
the symphysis and the promontory of the sacrum, palpated 
below the supposed growth. This would be impossible in a 
growth connected with the uterus. The floating kidney can 
generally be pushed back into its normal situation. 

522. Alterations and Degenerations. — During the active prog- 
ress of a myoma it becomes larger, swollen, and more ede- 



GENITAL TUMORS. 625 

matous as each menstrual period approaches; and, following 
the flow, it decreases in size and becomes more firm and re- 
sistant. In the submucous and interstitial varieties cessation 
of the menstrual function or the estabhshment of the chmacteric 
is delayed, so that a woman may continue to bleed for from 
five to ten years longer than would be required for the establish- 
ment of the climacteric in a woman whose uterus ^^'as free from 
disease. With the establishment of the menopause, however, 
the growth usually diminishes in size, and undergoes a process 
of atrophy. The groTvi;h becomes firm and hard, and its size 
remains fiked; or it may become soft, and, with this, a process 
of metabolism follows, b}^ which the grow1:h gradually disappears. 
In small growi;hs the same length of time after the climacteric 
the tumor may have almost entirely vanished. These changes 
also occasionally take place during the progress of a pregnancy 
or in nonpuerperal cases without our being able to assign a 
cause. Not infrequently a patient has been alarmed at the 
discover}^ through examination, of the presence of a fibroid 
gro^^-th, and some months or years later another investigation 
reveals no indication of its existence. If the second investiga- 
tion has been made by another physician, he may be inclined 
to believe that a misrepresentation had been made, and yet 
do an injustice in giving expression to such a suspicion. 

Edema {Hematoma). — Edema of large fibroids, especially 
of the interstitial variety, is not infrequent. The condition 
is caused by constriction or torsion of the pedicle, through 
which the venous circulation is obstructed, while the arteries 
continue to pump in the blood. The decreased circulation in 
such gro^^1:hs may result in edema as a first stage of a nec- 
robiosis. The interstices of the tumor become filled with serous 
fluid, so that the entire gro\\'th causes a sensation of indistinct 
fluctuation or elasticity, so marked that only the continuation 
of the groT\1:h with the cervix is sufficient to dift'erentiate it 
from an areolar glandular ovarian cyst. After the removal 
of such a growth an incision into its wall will permit the dis- 
charge of a large quantity of serous fluid. I once removed 
such a gro^^1:h, when a prominent surgeon examining it asserted 
that it was a fibrocystic tumor. An incision through the struc- 
ture, however, failed to reveal a single cyst, while nearly a 
gallon of fluid drained out of the groA^-th in the next two hours 
following its removal and incision. 

Fibrocystic tumors (Fig. 459) result from dilatation of the 
lymph-spaces in the tumor or degeneration of a portion of its 
structure, the formation of a cavity, or, in rare cases, separation 
of the structure of the tumor in edema. 

40 



626 



GYNECOLOGY. 



Calcification. — With the maturity of the tumor, and especially 
the interference with the circulation, the calcareous salts of 
the blood are deposited in the wall of the tumor, and cause 
a calcareous mass, or, at least, a shell, which envelops it. In 
the examination of such a case the sensation of pressure against 
bone renders it much harder and more resistant than the or- 
dinary mature fibroid. Not infrequently plates of bone will 
be felt to break beneath the palpating finger. Undoubtedly, 




Fig. 459. — Fibrocystic Tumor of the Uterus. 



they are similar cases which have given rise to the reported 
expulsion of uterine calculi. 

A submucous or interstitial fibroid having 
a change, the subsequent contractions of the 
expulsion. Amyloid degeneration has been 
patient. Fatty degeneration has been evident 
scopic appearance of cases I have removed, 
been asserted that fatty degeneration of such 
shown by the microscope. 



undergone such 
uterus cause its 
reported in one 
from the macro- 
although it has 
o^rowths is never 



GENITAL TUMORS. 627 

Colloid Myxomatous Degeneration. — This condition, accord- 
ing to Virchow, is an effusion of mucous fluid between the mus- 
cular bands. The presence of a mucin proHferation of the 
nuclei and small round cells permits of its being distinguished 
from simple edema. 

Inflammation, Suppuration, and Gangrene. — Inflammation 
of a growth may result from injury, traumatism, compression 
or obliteration of nutritive vessels of the tumor, and from septic 
infection following an exploration. Septic inflammation may 
follow an exploration or the delivery of a patient. The rapid 
changes which take place subsequent to the delivery of a patient 
who is suffering from a large fibroid may result in interference 
with its nutrition and in the development of inflammation 
and suppuration. Suppuration may take place external to the 
capsule, in the cellular tissue about it, or in the structure of 
the tumor. This may have been preceded by mortiflcation 
of a small part of an interstitial or a submucous growth. The 
gangrenous portions may be eliminated spontaneously, or may 
produce putrid infection. When a large growth has lost its 
vitality, and is still retained within the wall of the uterus, it 
may gradually disintegrate, slough, and be expelled into the 
vagina through the cervix as a large sloughing mass, or may 
produce such marked symptoms from putrid infection that the 
life of the patient will be sacriflced notwithstanding operative 
interference for its removal. Such conditions are readily con- 
founded with malignant disease. But recently I was called 
to see a patient who had been examined by a physician who 
assured her family that she w^as suffering from an incurable 
malignant growth, which must speedily terminate her life. 
The history of profuse hemorrhage and of an exceedingly offen- 
sive discharge, and the appearance of profound anemia and 
a condition resembling cachexia, aff^orded apparent confirmation 
of the correctness of his suspicion. The finger disclosed a 
large mass filling the vagina, which, instead of being soft and 
friable, as a cauliflower growth would be, was roughened on 
its inferior, but smooth upon its upper, surface, was quite mov- 
able, and a distinct pedicle could be recognized, which pro- 
jected from the cervical canal. The neck of the uterus was 
thin, pliable, and without any inflltrate, which demonstrated 
that the diagnosis of malignant disease was incorrect, and 
that the patient was suffering from a sloughing fibroid polypus. 
In cases of doubt the history, more or less firmness of the grow^th, 
the distinct arrangement of the structure, even when gan- 
grenous, and the absence of any cellular infiltrate are sufficient 
to afford a correct diagnosis. An abscess may develop either 
in the wall or within the growth itself. 



628 



GYNECOLOGY. 



Malignant Degeneration (Fig. 460). — Cancerous degeneration 
of a fibroid growth has not been demonstrated. The presence 
of the growth renders the uterus less resistant and faciHtates 
the probabiHty of malignant degeneration of the endometrium. 
The most frequent malignant degeneration, however, is the 
infiltration of the fibroid growth by sarcomatous processes. 




Fig. 460. — Myoma of the Body and Cancer of the Cervix. 



523. Mixed Growths. — Enchondroma, Sarcoma, Osteoma, and 
Carcinoma. — The origin of these growths is uncertain. It 
is possible that they must originate in one of two ways — either 
in transformation of the cells which produce other tissue species, 
or in an invasion in which the growth is penetrated by the 
neighboring proliferating masses. Thus, we have myochon- 
droma, myosarcoma, and myocarcinoma. The first of these 
is very rare. The second is more firm, and grows rapidly from 



GENITAL TUMORS. 629 

a small invasion. The normal filamentous structure of the 
fibroid growth is soon lost in a homogeneous mass, which rapidly 
becomes necrotic; the tumor then forms a mere thick shell. 
With the necrosis of the mass, not infrequentl}^ vessels are 
eroded, and extensive hemorrhage may take place into the 
cavity. The disease is not confined to the growth, but invades 
the surrounding healthy tissues. The enveloping cells are 
large, irregular, rich in chromatin, and contain several nuclei. 
Sanger asserts that all myomatous growths containing irrita- 
tion cells (myoklasken) are sarcomatous. 

Myocarcinoma arises from carcinomatous alteration of the 
surface of the polypus, or by development from the glandular 
constituents of an infiltrated adenomyoma. 

524. Complications. — The study of the progress of fibroid 
growth from its origin in the wall of the uterus to its subsequent 
extrusion, and the changes and lesions to which it may be readily 
subjected, will afford reasonable explanation for many com- 
plications which are associated with it and influence the prog- 
ress of the growth. Of these complications, the most im- 
portant, because one of the most frequent, is that of inflam- 
mation and the resulting adhesions. 

1. Inflammation, as w^e have already seen, may involve 
the structure of the growth or may influence only its super- 
ficial surface. The structure of the growth can undergo in- 
flammation from decreased nutrition by its extrusion into 
the peritoneal cavity, when it becomes a foreign body, which 
nature, in its efforts to protect the general structure, surrounds 
with plastic material, from which the tumor may receive ad- 
ditional and necessary nutrition, and which fixes it in relation 
to the structures immediately about it. Such adhesions may 
take place with the intestine, the mesentery, or the abdominal 
wall, and may lead, through traction upon the tumor, to still 
further thinning or attenuation of its pedicle, and, finally, to 
separation from the body of the organ, so that occasionally such 
growths are found removed from the original attachment and 
nourished through the inflammatory adhesions. The causes 
for inflammatory changes may be divided into (i) those incident 
to alterations in the tumor; (2) to irritation-changes in the 
peritoneum from the presence of the growth as a foreign body; 
(3) to infection. Infection may arise from disease of the ap- 
pendix, the Fallopian tubes, or through direct transmission 
from the intestinal cavity. 

2. Ascites. — A second, though less frequent, complication 
of myomata is ascites (Fig. 462). This is likely to be produced 
by an irritation of the peritoneum from pedunculated sub- 
peritoneal growths. (Fig. 463.) It is possible that it may 



630 GYNECOLOGY. 

be engendered by want of vitality in the growth, which makes 
it a foreign body and leads to irritation, which results in ascites. 
Ascites is much more frequent in malignant than in benign 
growths, and its presence should always awaken the suspicion 
that very grave changes have taken place in the growth. 

3. Disease of the Tubes (Fig. 461). — Disease of the Fallopian 
tubes as a complication of the presence of fibroid tumors is very 
common. It may be a simple hydrosalpinx or a pyosalpinx. 
Adhesions may be extensive, and very greatly complicate any 
operative procedure. The most frequent cause of this condition 
is undoubtedly the result of infection which has traveled through 
the uterus. The presence of the fibroid growths favors the 
congestion of the pelvis, and makes the tubal mucous mem- 
brane a more favorable soil. Pressure of the growth upon a 
Fallopian tube may interfere with its circulation, cause a disten- 
tion of its cavitv and the formation of a tubal collection. This 




Fig. 461.— Myoma Uteri Complicated by Pyosalpinx. 

defective drainage causes regurgitation into the pelvic perito- 
neum from the abdominal end of the tube, which sets up a peri- 
toneal inflammation, and produces a gluing up of the tube and 
the formation of a hydrosalpinx or pyosalpinx, according to 
the exposure to or absence of infection. 

4. Ovarian Cysts. — The existence of fibroid tumors dofes 
not necessarily increase the tendency to ovarian growths, nor 
does their presence preclude the development of cysts in the 
ovary. The presence of an ovarian cyst with its rapid develop- 
ment may greatly increase the distress of a patient who is suffer- 
ing from a large fibroid tumor, and may necessitate earlier 
resort to the physician for relief. In very large ovarian cysts 
a fibroid growth may frequently be overlooked, and detected 
only during operative interference in the treatment of the 
former. 



GENITAL TUMORS. 



631 



5. Pregnancy. — The presence of fibroid growtlis increases 
the tendency to sterility, but does not necessarily preclude 
the existence of pregnancy. Recognition of the existence of 
pregnancy is of the very greatest importance, as the progress 
of the condition may have a marked influence upon the rapidity 
of the growth, while the growth may fa^-or the premature inter- 
ruption of the progress of pregnancy. This complication is 




Fig. 462. — A Myoma Which, from the Associated Ascites, Had Been Mistaken 

for Pregnancy. 



of SO much importance that it may be studied from various 
standpoints. 

525. (a) The Influence of the Myoma upon Conception. — 

It can be readily understood that the presence of a fibroid 
growth — for instance, of the polypoid or submucous character — 
renders the mucous membrane of the uterus unprepared for 



632 



GYNECOLOGY. 



the retention of the fecundated ovum, and not infrequently 
the removal of a polypus from a woman who has been sterile 
for a number of years is very shortly followed by conception, 
even though years of sterility had preceded. The engorge- 
ment of the uterine mucosa, occasioned by the presence of a 
sessile submucous or of an interstitial growth, which encroaches 
upon the uterine canal, the profuse and irregular hemorrhages 
accompanying its progress, associated with the constant and 
excessive secretion from the glandular structure, present con- 
ditions exceedingly unfavorable for the fecundation of the ovum. 
526. (b) Influence of Pregnancy upon the Myoma.— The in- 
creased congestion of the uterus incident to pregnancy causes 






Fig. 463, — Tumor Shown after Removal. 



greater nutrition of the growth, results not infrequently in its 
rapid increase in size, and the growth which was situated in the 
pelvis is of itself raised out of it, and forms a more formidable 
mass. In some cases the growth is slow, adhesions may so fix 
and bind down the uterus that it can not rise out of the pelvis, 
and we may have as a result an impaction of a mass in the 
pelvis similar to that which occurs in the gravid retroflexed uterus. 
Sometimes the rise of the growth in the pelvis may be rapid, or 
it may be situated low in the pelvis, and not emerge from it 
until between the sixth and seventh months. Intraligamentary 



GENITAL TUMORS. 



633 



growths become altered by the pressure and cause very marked 
distress. The fibroid polypus or submucous tumor is sometimes 
extruded into the vagina, whence it may be removed without 
any indication of interference with the pregnancy. Marked 
changes in size, form, and consistence of the uterine growth may 
be noticed. The increase in size is often due to edema. Venous 
engorgement frequently occurs as a result of obstruction of the 
veins, while the blood is continually poured into the structure by 
the less readily controlled arteries. Where a number of fibroid 
growths are situated together in the pelvis they not infrequently 
become nonpedunculated subserous growths, and often become 
flattened from pressure. The circulation can be obstructed to 




Fig. 464. — Myoma Complicated by Pregnancy, 



such a degree as to result in necrotic changes. Such changes 
require early and prompt interference in order to save the life of 
the patient. 

527. (c) The Influence of the Myoma upon Pregnancy. — ^An 
intrauterine growth, covered as it is by mucous membrane, pre- 
disposes the subject to increased bleeding. This hemorrhage and 
the changes in the uterine mucous membrane may be so marked 
as to result in premature interruption of pregnancy ; or the ovum 
may be lodged low in the uterine cavity, causing the formation 
of the placenta over the cervix, — what is known as placenta 
praevia, — in which the life of the mother will become more 



634 GYNECOLOGY. 

endangered as the pregnancy progresses. The situation of the 
tumor may favor retroversion of the gravid uterus and its im- 
paction in the pelvis, or the tumor itseh may be impacted with 
the development of the pregnancy. The presence of a fibroid 
growth, with its pressure upon the tubes, may cause the develop- 
ment of a tubal pregnancy, which may remain unsuspected until 
its rupture into the abdominal cavity occurs, with the accom- 
panying peril to the patient. 

528. {d) Influence upon Labor. — In the majority of small 
fibroid growths, especially those which have not attained to a 
size larger than a walnut or an orange, the presence of the growth 
produces but slight, if any, influence upon the progress of the 
labor. Tumors of a larger size, which are situated in the pelvis, 
may interfere with labor and require operative interference for 
their previous removal. Occasionally, with changed position of 
the patient and elevation of the hips, the tumor may be pressed 
out of the pelvis, or a tumor situated so low in the pelvis under 
the dilatation of the os and elevation of the cervix as the dilata- 
tion progresses, may be lifted out of the pelvis. Interstitial and 
subserous growths, with a broad base, cause irregular and in- 
effective uterine contractions, which affect the progress of labor. 
The existence of myomata has been found to greatly complicate 
the results. Winckel, comparing the statistics of one hundred 
and forty-seven cases of labor complicated with myomata with 
those suffering from contracted pelves, said 5 to 6 per cent, of 
parturients with contracted pelves perish during labor, but when 
complicated with myomata, 50 per cent, succumb. The infantile 
mortality is often more serious. Nauss found the infantile mor- 
tality to be 66 per cent. Lefour, in three hundred cases ob- 
served, gives 77 per cent. Large subserous growths, when above 
the pelvis, in or near the fundus of the uterus, exert no influence 
upon the progress of the labor. Cervical growths, however, are 
very important, as from their situation they may occupy a 
position below the level of the cervix, and necessarily interfere 
with the delivery of the fetus, but even when the growth is thus 
found in the pelvis it is often spontaneously raised as the process 
of dilatation proceeds. Submucous growths may be extruded 
into the vagina previous to the inception of labor and then be 
removed. If the tumor becomes edematous, it is more com- 
pressible and less of an obstacle to the progress of delivery. 

529. Course and Prognosis. — Many of these growths, espe- 
cially when small, produce very few symptoms, and those quite 
vague. Others cause serious disturbance until the occurrence of 
the menopause, after which the great majority of tumors undergo 
atrophy and diminish by induration during the process of in- 
volution. The process of atrophy is occasionally hastened by 



GENITAL TUMORS. 635 

pregnancy, so that patients who have been recognized as suffering 
from a fibroid growth have the tumor entirely disappear by the 
completion of the pregnancy ; or, in other cases, during the sub- 
sequent convalescence. Occasionally, there is a marked breaking- 
down of the health, associated with fibrous cysts or fibromyomata, 
and particularly after the critical age. The tumors that remain 
quiescent are not necessarily small, but can reach to the level of 
the navel, so that the patient may be entirely ignorant of their 
presence and only be made aware of the existence of the growth 
by an examination that is made for some intercurrent condition, 
or for the treatment of symptoms produced by the tumor, of the 
cause of which the patient had previously been in ignorance. In 
the majority of cases the tumor does not threaten life either 
directly or indirectly. In this respect these growths are quite 
different from carcinoma or an ovarian tumor. The carcinoma 
demands immediate operation, as soon as discovered, for life is 
destroyed by its progress ; but in myomata such advice must be 
modified, for in many cases the growth is not even the cause of 
the disease for which the aid of the physician is sought. In 
others it may be productive of disturbance. In myomata of large 
size, which reach above the umbilicus in young individuals, the 
prognosis as to time is good, but there are possibilities of it 
becoming worse. In a woman who has not reached the age of 
thirty-five years, and a tumor attains a size corresponding to that 
of a pregnancy at full term, one can with security assert that the 
life of the individual is threatened, and the capacity for suffering 
must be limited. Attention should be directed to the symptoms 
that threaten life. The operation in such cases is no longer 
elective, but necessary, as the percentage of danger from the 
operation is more trifling than from the unfavorable influence 
produced by the growth of the tumor. In such cases, in order to 
produce conviction we should be able to assert that the operation 
is advisable, and can not be postponed for ten or twenty years 
with the hope that the patient will still manifest good powders of 
resistance and a fair chance for recovery. If the tumor comes 
under observation at a later date, near the middle of the flfth 
decad, — about forty-three to forty-five years of age, — we must be 
governed by the symptoms. It is possible that the tumor may 
swell during menstruation, and that after its final cessation a 
more secure and much more considerable diminution appears. 
In such cases we can wait until symptoms appear. In all cases 
the prognosis is dependent upon the age and its relation to the 
tumor. Great size of the tumor and its complex symptoms affect 
the future course. All complications that increase the size of the 
tumor render the prognosis the worse, the younger the age of 
the patient. In these cases we have to determine that not the 



.UJfA».'--S'- , T" . ... :.. iv-,-. * • - . '■ TZ^ 



636 GYNECOLOGY. 

tumor but the complications are the cause. Complications that 
may be regarded as hazardous in the young are less serious in 
the older, because the longer duration of the disease renders the 
organism more accustomed to its existence. The prognosis is 
very bad in cases of severe heart affections, as fatty degeneration, 
though this is difficult to recognize in the living. Other com- 
pHcations may render the prognosis of the myomata bad, but 
not necessarily make the prognosis of operation worse. The first 
indication of heart affection should be regarded as an indication 
for prompt operation. The prognosis is rendered much worse if 
the myoma has undergone a malignant degeneration, which, 
however, is rare. The rapid growth of the tumor is not neces- 
sarily an indication of malignant change, but more of cystic 
degeneration, which renders the prognosis of the further con- 
tinuation of the growth worse, approaching in this respect the 
ovarian condition. The prognosis of all small tumors, especially 
those which cause more or less hemorrhage, is not necessarily 
unfavorable. The danger is never so great as it appears to the 
patient. The discomfort produced by the condition and the 
anxiety about further duration and increase of bleeding impel the 
patient to consult her physician. In such cases it is difficult to 
arrive at a correct judgment, as the patients do not appreciate 
the fact that life is not necessarily threatened when menorrhagia 
is profuse. In the consideration of methods of treatment we 
must keep in mind the fact that the productive activity is injured, 
even though a bad prognosis is not to be asserted. The danger 
lies in the long duration of hemorrhage, which thereby renders 
worse the general condition. The prognosis is more grave when 
there is more marked general disturbance. In many cases the 
appearance of hemorrhage can be regarded as a favorable indica- 
tion, as it proves that the spontaneous discharge of the tumor is 
taking place, following which the prognosis is improved. 

While it is true that a fibroid growth usually undergoes an 
abatement of its symptoms with the advent of the menopause, 
yet it should not be forgotten that the existence of such ^ growth 
generally delays the climacteric beyond the ordinary period of 
life at which it should occur. Occasionally, the natural evolution 
of a tumor, which results in its conversion into an extraperitoneal 
or intraperitoneal growth, may cause rupture of its pedicle, from 
the weight of the tumor alone or from thinning of the pedicle. 
By straining in defecation or in vomiting, a polypus may be ex- 
pelled. The rupture of a pedicle may limit the subsequent prog- 
ress of the growth, or it may remain grafted to the point where 
it has formed adhesions and be subsequently nourished, or it may 
lie free in the peritoneum and undergo mummification. A more 
serious spontaneous extrusion is mortification or gangrene of a 



GENITAL TUMORS. 637 

tumor which has been expelled toward the uterine cavity. Per- 
foration of some of the neighboring organs may occur, as, the 
bladder, the rectum., the rectovaginal pouch, or the abdominal 
wall. The two former conditions end in death; the latter, in 
possible recovery; or, finally, the tumor may be absorbed. 
Causes of death are profound anemia from repeated hemorrhage ; 
successive attacks of chronic peritonitis ; disease of the kidneys ; 
uremia and heart failure ; rupture of cyst ; or inflammation and 
gangrene. Sudden death has been observed as a result of em- 
bolism. Exploratory puncture favors the production of thrombi 
in the large venous sinuses. Death from shock after intravenous 
rupture has been reported. In very small growths which have 
been extruded beneath the peritoneum, and by their relations 
show no evidence of taking on growth, it is preferable that the 
patient should be left unaware of their existence. The various 
complications to which these growths are subject ; the alterations 
which they may undergo during their progress; the influence 
upon the health of the individual from pressure upon important 
viscera; the danger from separation of growths and subsequent 
gangrene ; the possibility of their continued nutrition and growth 
subsequent to the menopause ; and the occasional malignant de- 
generation of the mass, associated with the diminished mortality 
by early operative procedure, particularly that of hysterectomy, 
would render it advisable that the extirpation of the growth 
should be practised. In the young the possibility of the occur- 
rence of pregnancy with its attendant dangers is an important 
factor, and one which may be an indication for treatment. 
When a woman possesses a condition which insures a maternal 
mortality of 50 per cent, and an infantile loss of 75 per cent, 
or over, it becomes a serious question whether she should be 
advised to marry, or, if married, should not be subjected to 
prompt operative interference. 

530. Treatment.— The mere discovery of the existence of a 
myoma must not be considered as a necessary indication 
for its removal, or even treatment. In this respect myomatous 
tumors differ from ovarian growths and from cancer, for the 
latter must be removed early, because their continued existence 
results in destructive influences upon the organism. The 
myoma must cause symptoms in order to indicate interference. 
The external relations of the patient must play a great role 
in the method of treatment — the capacity of resistance, the 
ability to undergo rest during menstruation, and to avoid severe 
bodily labor; consequently the treatment is different in the 
working class, who can not rest, from that Avhich must be prac- 
tised in those who are able to take care of themselves. There 
are some cases in which hygienic and dietetic rules must govern. 



KlvliJt.^ 'V ' 'x*v 



638 GYNECOLOGY. 

Neither the growth of the tumor nor the strength of the hemor- 
rhage will necessarily be influenced by the methods of treat- 
ment; but by the avoidance of severe bodily effort and the 
promotion of nutrition, disturbance of the health equilibrium 
is avoided. 

The patient should be cautioned as to her manner of dress, 
and advised to wear loose clothing, since it would be exceed- 
ingly detrimental to force down into the lower part of the pelvis 
a myomatous uterus by wearing a tight corset. Tight clothing 
over an abdomen containing such growths may very readily 
produce inflammation which will lead to extensive and un- 
fortunate adhesions. When the abdominal wall has become 
greatly weakened by previous distention or the weight of a 
large tumor following the climacteric, the comfort of the pa- 
tient may be greatly enhanced by wearing a binder or support 
which will prevent the organ from falling forward. In such 
cases and in growths predisposed to the occurrence of torsion, 
a radical operation is indicated. Schroder attempted to fasten 
very movable tumors by sutures through the abdominal wall. 
Such a plan of treatment is not only unsatisfactory but dangerous. 
The very profuse hemorrhage which frequently occurs requires 
that the nutrition should be carefully maintained and that 
all excesses of Bacchus and venery should be avoided. Pre- 
ceding and at the menstrual period the patient should be kept 
in bed and an ice-bladder or cold applications should be placed 
over the abdomen. Tea and coffee should be interdicted, be- 
cause experiments have demonstrated that both these articles 
increase the tendency to profuse bleeding. Various baths 
and mineral waters have been advocated as especially efficacious. 
Among these are the Kreuznach, Tolz, and Halle, in upper 
Austria, which are largely impregnated with iodin and bromin, 
and the Franzensbad and Elster, in which sulphur is an im- 
portant element. These waters probably exert their influence, 
not so much b}^ their direct effect upon the tumor as by 
the improvement of general nutrition. The health is built up, 
complete rest is secured, and the appetite is improved, and 
thus more or less relief is obtained. The treatment may be 
divided into: 

(a) Medical. 

(b) ElectricaL 

(c) Surgical. 

531. (a) Medical Treatment. — The medical treatment should 
consist in the employment of remedies and hygienic measures 
directed to promote the general nutrition of the patient and 
ameliorate the unpleasant symptoms. Such treatment must 
be largely symptomatic. The list of remedies advocated for 



GENITAL TUMORS. 639 

the treatment of uterine myomata is very extensive; but, as 
is usually the case, the larger the list of remedial agents, the 
less beneficial the influence exerted. Notwithstanding the 
effective results that have been attributed to many different 
remedies, the history of myomatous growths discloses that they 
normally undergo peculiar changes, becoming sometimes larger 
and at others smaller. Occasionally the growth disappears 
without any assignable cause. Such fortunate results have 
added to the reputation of certain remedies, when similar con- 
ditions would probably have taken place had they not been 
administered. The agents which are most likely to exert an 
influence upon the progress of the growth are those which pro- 
duce an effect upon the muscular coat of the organ, and belong 
to that class known as oxytocics, of which ergot is the principal. 
Ergot may be administered by the stomach, by the rectum, 
or by hypodermic injection. Its employment by the stomach 
causes more or less disturbance of the digestive tract, nausea, 
and vomiting. Moreover, in order to secure any beneficial 
effect from its employment, it must be continued over a long 
period of time, which renders this method of administration 
objectionable. Ergot in combination with a vegetable astringent 
will sometimes exert a favorable influence in decreasing and 
arresting a severe hemorrhage. It may be employed in the 
following combinations : 

R. Ext. ergot f^j 

Extract hamamelis, 

Tinct. cinnamon, aa f ^ ss. M. 

SiG. — f^j every two or three hours. 

Or: 

R . Ergotin, gr. ij 

Hydrastinin hydrochlorate, gr. i. 

M. ft. capsulas No. XXX. Sig. — A capsule to be taken every three or four 
hours. 

The fluid extract of cotton-root or an extract of Ustilago 
maidis, the ergot of corn, acts similarly to ergot, though to a 
less marked degree. When a patient suffers from expulsive 
efforts of the uterus, these may be ameliorated by the addition 
of extract of cannabis indica, gr. J to each dose. Ergot is most 
effective when administered by hypodermic injection, using 
either the sterilized fluid extract, the normal liquid, or ergotin. 
The agent should be thoroughly aseptic, should be injected 
in close proximity to the tumor, preferably in the abdominal 
walls, and the caution should be taken to make the injections 
deeply into the muscle, since they will then be less likely to be 
the cause of abscess. Ergot acts in two ways: By stimulating 
the muscular coats of the blood-vessels, thus cutting off the 



TTJTTr^-TT-. 



640 GYNECOLOGY. 

supply of blood sent into the uterus ; and, secondly, by increasing 
the activity of the muscular structure of the organ. Fibroid 
growths which are situated in the uterine wall are by its in- 
fluence more readily expelled, either intraperitoneally or extra- 
peritoneally. To be efficacious, the drug must be continued 
over a long period of time. When thus employed, it exerts an 
influence upon the muscular coat of the blood-vessels through- 
out the body, increases the danger of arterial sclerosis and the 
establishment of pathologic processes more serious than those 
for which the drug was administered. Among some of the 
drugs for which a reputation has been made by the retrogressive 
processes through which fibroids naturally pass may be named 
the potash and ammonium salts, particularly the bromid, the 
iodid, and the chlorid of ammonium. How much influence 
any of these drugs will exert upon the progress of the disease 
is an undetermined question. Among other drugs that have 
been employed are sulphuric and gallic acids, turpentine, can- 
nabis indica, extract of hamamelis, extract of hydrastis can- 
adensis, and the active principles of the latter agent, hydrastin 
and hydrastinin. The latter agents exert a very favorable 
influence by constringing the blood-vessels, and thus serve to 
control hemorrhage. Efforts have been made to bring about 
the absorption or destruction of fibroid tumors to compensate 
for the deprivation of certain nutrient elements which enter 
largely into the composition of the growth. A diet composed 
of the carbohydrates seems to have been in some few cases effec- 
tive. Sir J. Y. Simpson, recognizing that the calcareous de- 
generation of a fibroid limited its further growth, purposed 
to accomplish this phenomenon by the administration of large 
doses of chlorid. of calcium, but he soon found that this drug 
produced calcareous plates in the aorta and in the valves of the 
heart, and thus caused conditions much more grave than that 
for which it was given. In recent years the extract of thyroid 
gland has been advocated to reduce the size of growths and 
assist in the arrest of hemorrhage. As patients vary to a great 
degree in their susceptibility to the influence of this agent, it 
must, therefore, be employed carefully, increasing the dose 
gradually from three to five grains a day to the largest amount 
the sensibility of the patient will permit. In exophthalmic 
goiter, or in irritable conditions of the heart, the drug is badly 
borne, even in small doses. In some cases of fibroid growths 
in which I have employed it, the drug has produced such an 
effect upon the nervous system that its use had to be discon- 
tinued. Without question, it exerts an infiuence upon the 
lining structure of the uterus, and to this extent is beneficial in 
lessening the tendency to hemorrhage. Polk and Mann claim to 



GENITAL TUMORS. 641 

have seen very pronounced effects from this drug in the dim- 
inution of the size of the tumor, but that it has any permanent 
influence is very questionable. Shober employed the mammary 
gland extract with apparent benefit in a limited number of 
cases, but the results do not seem to have given sufficient encour- 
agement to continue it. Probably the extract of the suprarenal 
gland or its active principle, adrenalin, is more effective than any 
of the other agents we have mentioned in stimulating the muscular 
coat of the blood-vessels, thus lessening the tendency to hemor- 
rhage. Various local measures have been employed, such as 
injections into the vagina. These, however, can have no in- 
fluence on hemorrhage from the uterus, as the coagulation of 
the blood in the vagina will be insufficient to aft'ord any ob- 
struction to the severe uterine hemorrhage. Ice-water w^as 
formerly employed, later hot water. Both agents are efficacious 
in the field of obstetrics, but they have but little influence upon 
fibroid tumors. The agent must come directly in contact with 
the affected endometrium to be of any service. When hemor- 
rhage is very marked and uncontrollable, and threatens the 
life of the patient, the vagina or even the uterine cavity may 
be packed with iodoform gauze, which acts as a tampon and 
thus controls the bleeding. When the uterine canal is opened, 
its cavity may be irrigated with hot water or vinegar and water, 
or a solution of perchlorid of iron, tincture of iodin, and other 
agents for the purpose of arresting hemorrhage. These agents 
are sometimes quite effective for a length of time, but their 
use is not unattended with danger. The uterine canal should 
be so patulous that the subsequent drainage can be complete, 
but even in such cases the method of treatment is not infrequently 
attended with danger. I well remember a patient in my early 
experience who had a large fibroid tumor, which occasioned 
frequent attacks of profuse bleeding. The cervical cavity was 
quite patulous, and with a uterine syringe I injected tincture of 
iodin into its cavity. Almost before the syringe could be with- 
drawn the patient complained of tasting the drug, and within 
a few moments she had a most violent attack of pulmonary 
edema, which threatened her life, and from which she recovered 
only after a protracted illness. Moreover, this state was followed 
by prolonged mental disturbance. Needless to say, I have 
not been inclined to regard this plan of treatment with a great 
deal of confidence. 

532. (b) Electric. — Electricity has been practised in the 
treatment of fibroid growths for many years. The methods 
of application of the agent were crude, and not infrequently 
were attended with great danger, especially when punctures 
were made through the abdominal wall directly into the tumor 

41 



ii/S^Jfj.H; 



642 GYNECOLOGY. 

by an insulated needle, which thus produced a direct and localized 
influence upon the structure immediately in contact with the 
poles. It remained for Apostoli, by his method of measuring 
the current and fixing the direct dosage, to evolve a plan of 
treatment which can be practised with a certain degree of pre- 
cision. Under ordinary means the passage of a current of 
from five to ten, or at most twenty, milliamperes is attended 
with considerable discomfort. By his apparatus and method 
of procedure from loo to 200 milliamperes are employed. This 
is accomplished by the application over the external surface 
of a large, comparatively inactive electrode, while a more active 
electrode is introduced into the vagina, or, preferably, into 
the uterine cavity. He further defined the influence of the 
positive and negative poles. The positive pole was recognized 
as producing a decomposition of the fluids about it, which 
resulted in the accumulation there of an acid, while about 
the negative pole accumulated alkaline fluid. The former 
is the more destructive in its influence, and hence is more par- 
ticularly of value in diseased conditions of the mucous mem- 
brane which cause hemorrhage. The application of the posi- 
tive pole within the uterus causes an electrolytic or cauterizing 
action, which results in coagulation of the blood in the vessels 
and in the arrest of bleeding. The negative pole, on the other 
hand, by its influence produces edematous inflltration of the 
tissues at some distance from the pole, and the subsequent 
absorption decreases the size of the growth. For the practice 
of Apostoli's treatment, then, are required: First, an electric 
battery sufficiently large to give a current strength of from 
200 to 300 milliamperes without its wearing out too rapidly; 
second, a galvanometer capable of measuring 500 milliamperes; 
third, a rheostat, by which the strength of the current can 
be gradually increased. The current chooser — an instrument 
by which the current can be changed from positive to negative 
without the removal of electrodes — is important. It must 
be kept in mind in the use of this instrument, however, that 
the strength of the current must be very greatly reduced before 
such a change is made, as otherwise the patient would receive 
a violent and painful, if not a dangerous, shock. 

Electrodes. — The external electrode, to be placed over the 
abdomen, is of large size, and consists of the clay pad of Apostoli, 
of the bladder or water electrode, as advocated by Martin, or 
of a towel wet with a salt solution and over which the electrode 
is placed. The intra-uterine electrode consists of a probe in- 
sulated within a couple inches or more of its point, as may 
be desired. An ordinary probe with a gutta-percha hood which 
can be slid over it affords an efficient electrode. The electrodes 



GENITAL TUMORS. 643 

are placed in position before the current is turned on. The 
latter is applied gradually, watching the galvanometer and the 
expression of the patient to ascertain the sensibility. The 
internal electrode is made of platinum or carbon, these agents 
having more endurance. As large quantities of strongly acid 
material accumulate about the electrode, the less durable metals 
would be very quickly destroyed by electrolytic action. In 
the application of electricity the vagina should be thoroughly 
cleaned in order that no infection shall be carried into the uterine 
cavity. It is recognized . that electricity is a powerful anti- 
septic, but it is only in the stronger doses that it exerts such 
an influence. The application of electricity may be made 
two or three times a week, according to the intensity. When 
strong currents are used, but once a week is preferable. The 
seance lasts from five to fifteen minutes. Previous to the 
application of the external electrode the skin of the abdomen 
should be carefully examined for breaks in the corium, by 
denudation from scratching, or from the presence of furuncles. 
Any irritated points should be treated, and should be excluded 
from contact with the electrode by the application of collodion 
or pieces of plaster to insulate it. The external electrode is 
placed upon the abdomen and is connected with the battery; 
the internal electrode, also connected, is introduced, but with 
the precaution to have the current closed. The current is 
then opened slowly and carefully, and is gradually increased 
to the point of tolerance. The current is gradually reduced 
before the withdrawal of the electrode, to prevent the patient 
from being subjected to a severe shock. In the beginning of 
the treatment it is important that the current should be governed 
with the greatest care, and currents of moderate intensity 
only employed, until the degree of toleration is determined. 
It is difficult to fix the number of applications to be required— 
generally from twenty to thirty. 

Electropvincture of the Myoma. — Occasionally, the situation 
of the tumor may be such as greatly to displace the external 
OS and to render the canal tortuous and difficult for the intro- 
duction of the electrode. In such cases puncture may be made 
into the myoma through the anterior cervical wall. Just as 
rigid antisepsis should be practised for this procedure as for 
the most serious operation, and as it is not infrequently quite 
painful, an anesthetic should be employed. The puncture of 
the vagina is from one-half to one centimeter deep, and is per- 
formed without the employment of a speculum. Previous 
examination will disclose the position of the uterine artery, 
which should be avoided; also, care should be exercised not to 
injure the bladder or intestines. 



644 GYNECOLOGY. 

Electricity exerts its influence in three ways: 

(a) In the diminution of the tumor from one-fifth to one- 
half of its original size. Complete disappearance is exceedingly 
rare. 

(b) In a most marked influence upon the hemorrhage. 

(c) In the relief of pain. 

The disappearance of pain and the arrest of hemorrhage 
necessarily result in the improvement of the general condition 
of the patient. Apostoli gives the following contraindications: 
First, hysteria; second, intestinal catarrh; third, pregnancy; 
fourth, malignant degeneration of the tumor; fifth, fibrocystic 
tumors. 

Some of his followers do not consider hysteria an absolute 
contraindication, but Apostoli has made the observation that 
the hysteric possess a very great intolerance to the electric 
current, making it impossible during the course of a sitting to 
introduce a sufficiently high current to bring about favorable 
results. In intestinal catarrh the current has a strong in- 
fluence on the solar plexus, which calls forth severe contraction 
of the intestinal muscle. It can be readily understood that 
the presence of malignant growths must necessarily offer a 
direct contraindication to the electric treatment. The diag- 
nosis is sometimes difficult to determine. Kellogg has asserted 
that in a myoma which after the menopause shows a rapid 
growth malignant degeneration is undoubtedly taking place, 
and that electric treatment should be withheld. In fibrocystic 
tumors the gas accumulation after the electric treatment may 
lead to suppuration. Gehrung, in order to avoid this, employs 
a puncture cannula, so that the fluid contents of the tumor 
can be drawn off. The presence of pus in the adnexa, as men- 
tioned by Apostoli, is a very frequent complication, and one 
often difficult to recognize. The employment of electricity 
in such cases is unexceptionally harmful. It is unnecessary 
that the inflammation should have gone on to suppuration in 
order to make the treatment objectionable. Very acute or 
subacute inflammation in the environment of the uterus is a 
positive contraindication to electrotherapeutics. 

Further, a very important contraindication for electric 
treatment depends upon the situation of the tumor and its 
relation to the uterus, and justifies the following statement: 

(a) In subserous tumors, particularly when they are pedun- 
culated, electric treatment will have but little beneficial effect, 
and is likely to prove injurious. 

(b) A pedunculated submucous fibroid affords no special 
advantages for electric treatment. 

In an inconsiderable number of cases suppuration of a poly- 



GENITAL TUMORS. 645 

pus has resulted from intra-uterine electric treatment. Not 
infrequently has a fatal result appeared, or total extirpation 
of the suppurating organ been performed, with or without 
favorable result. Other contraindications, in addition to those 
named, are heart failure and acute nephritis. In very hard 
tumors the employment of electricity is opposed by Parsons, 
as they can not be influenced by it. 

Colossal Tumors. — In studying the influence of electricity 
upon the tissues we must take the polar and the interpolar. 

1. The Polar Influence. — This incidentally depends on the 
progress of electrolysis of the soft tissues. In the passage of 
the current from the metallic body, in fluid destruction which 
takes place in the salt solution, and about the positive pole 
an acid is formed, while the metal surrounds the negative. 
Similar changes occur in the tissues of the body, so that about 
the positive pole acid material, such as carbonic acid and chlo- 
rin, is set free. In the cathode watery material the alkalies 
are collected. It is asserted that these materials in the nascent 
state exert a strong chemic influence. Albumin is coagulated, 
the vessels are narrowed, and a hard, dry, brow^n-red slough 
occurs, while under longer employment the tissues are destroyed. 
About the negative pole a soft, succulent, glue-like, easily 
scraped off white slough occurs, as if one had employed con- 
centrated caustic potash. Consecutive hemorrhages may follow 
the employment. The negative current is absorbent, and is 
much more painful than the positive. Investigations have 
demonstrated that the positive pole acts more on the cell germs 
or cellular tissue, and the negative upon the protoplasm. The 
latter is more diffuse, while the former has a sharper limita- 
tion. 

2. The Interpolar Method. — Apostoli's critics assert that 
the methods are not without danger. The principal dangers 
of myoma operations are hemorrhages and sepsis, but we have 
radical operations which present various series of dangers, 
embolus, pneumonia, ileus, and death from chloroform, with- 
out considering the later disturbances of nutrition. When we 
come to consider the advantages and disadvantages of electric 
treatment, we are led to the conclusion that it should be conflned 
to the uncomplicated cases, while those cases which threaten 
life should be subjected to operative treatment. 

533. {c) Surgical. — -The surgical treatment of fibroid growths 
may be either palliative or radical, but we will consider the 
procedures under the two divisions of vaginal and abdominal, 
according to the route by which the tumor is most accessible 
and may most readily be subjected to treatment. 



i^.,-»«' 



646 GYNECOLOGY. 

The vaginal procedures consist in: 

1. Dilatation and curetment. 

2. Incision of the cervix. 

3. Incision of the capsule. 
4 Removal. 

(a) Torsion. 

(b) Incision of the pedicle. 

(c) Enucleation. 

(d) Morcellement. 

5. Ligation of the vessels. 

6. Hysterectomy. 

The abdominal route includes: 



Castration. 

Ligation of vessels. 

Myomectomy, 

Enucleation. 

Supravaginal amputation or partial hysterectomy. 

Panhysterectomy. 



Vaginal Procedures. 

534. (i) Dilatation and Curetment of the Uterus. — Dilatation 
of the uterus may be indicated as the first stage in treatment of 
the uterine growth or for the purpose of diagnosis. It may be 
accomplished by the mechanical dilatators of Hegar, but without 
tearing the neck they will not afford sufficient dilatation of the 
cervix to permit the introduction of the finger. The preferable 
method of dilatation is the employment of a laminaria tent, and 
the vagina should be thoroughly cleansed and rendered as nearly 
aseptic as possible before its introduction. The os is exposed 
by a Sims speculum or perineal retractor. The cervix is seized 
with a double tenaculum, the os exposed, the plug of mucus 
filling the cervical cavity removed, and the canal thoroughly 
disinfected; then as large a tent is selected as can readily be 
introduced, or, when the canal is pretty well dilated, a nest of 
tents may be employed. These tents should be previously 
sterilized by heat and placed for a few minutes before their 
employment in a saturated solution of iodoform in ether or in a 
mixture of equal parts of carbolic acid and alcohol. After the 
introduction of the tent iodoform gauze is placed beneath it to 
protect the parts from infection and to keep the tent from being 
extruded. Usually, at the end of twelve hours the cavity will 
be sufficiently dilated to permit the introduction of the finger. 
If the dilatation is insufficient, the canal can be enlarged by the 
employment of Hegar's bougies, or with a second series of tents. 
The exposure by dilatation permits the situation of the growth 
and its size and relations to be recognized. The curet is used 
in a manner similar to that described in the treatment for endo- 
metritis. It should be done thoroughly to remove the hyper- 



GENITAL TUMORS. 



647 



trophied mucous membrane. This removal of the hypertrophied 
tissue ruptures and scrapes away the diseased vessels, and is 




Fig. 465. — Incision of Cervix to Expose Intra-uterine Myoma. 

effective in the arrest of hemorrhage. It should be followed by 
careful irrigation of the cavity, and subsequently by painting 



K^.Jk.r.f'h 



648 



GYNECOLOGY. 



the canal with tincture of iodin or carbolic acid, or with a 
mixture of these two agents. When there is much hemorrhage, 
following the use of the curet, the uterus should be packed with 
iodoform gauze. Curetment of the uterus, while effective in 
decreasing the hemorrhage, is not unattended with danger. The 
injury to the surface of the tumor may cause an inflammation, 




Fig. 466. — Cervix and Capsule Incised, the Latter Pushed Back. 



which will interfere with its nutrition, and by the presence of 
germs which have been introduced during the procedure, may 
eventuate in suppuration and extensive necrosis. When the 
myomata project into the uterine canal, and the latter is irregular, 
difficulty is experienced in reaching all points of the canal with 
the curet, and the plan of treatment will not be effectual. In 



GENITAL TUMORS. 



649 



small tumors that cause severe hemorrhage curetment is of no 
value, and nothing short of the removal of the tumor will be of 
service. 

535. (2) Incision of the Cervix. — This procedure is another 
palliative measure (Fig. 465). It consists in making a bilateral 
or an antero-posterior incision through the cervix, which dimin- 
ishes its resistance and facilitates the extrusion of the tumor. 
When the body of the uterus is well dilated by the growth, this 
procedure permits the tumor to be more rapidly extruded into 
the vagina, and it is thus rendered more accessible. It was 
formerly very generally practised as a preliminary to the adminis- 
tration of ergot, but not infrequently the rapid separation of the 




Fig. 467. — Removal of Myoma by Torsion of Its Pedicle. 



tumor thus induced led to gangrene or necrosis of the growth 
and to fatal infection of the patient. Incision of the cervix will 
frequently prove of value as a first step in operative procedure 
for the removal of a growth. 

536. (3) Incision of the Capsule (Fig. 466). — In sessile sub- 
mucous or interstitial fibroids which project into the cavity of 
the uterus the more rapid expulsion of the tumor can be accom- 
plished by incising the uterine surface of the tumor into and 
through its capsule. The incision is accomplished by wrapping 
the blade of the knife with adhesive plaster at a necessary dis- 
tance from the point, as advocated by Atlee, or the thermo- 
cautery or galvanocautery knife can be employed. The wall is 



650 



GYNECOLOGY. 



pushed back and the tumor partly enucleated, which decreases 
the resistance. Subsequent contraction promotes the extrusion 
of the tumor into the uterine cavity and renders it a pedunculated 
growth. This operation, though apparently but a slight one, is 
not free from danger, for the rapid extrusion which follows its 
performance not infrequently causes loss of vitality of the tumor 
and degenerative processes which may be dangerous to the life 
of the patient. The operation is advisable only when it is 
employed as one of the preliminary stages to the removal of 
the growth. When such a procedure has been adopted, it is 
preferable that the tumor should be subjected to complete ex- 
tirpation. 

. 537. (4) Removal of the Growth. — (a) Torsion. — (Fig. 467.) 
When the growth is situated in the vagina, after having been 




Fig. 468. — Incision of Pedicle of Myoma. 



extruded from the cavity of the uterus, and hangs by a pedicle, 
it can very readily be removed by torsion. The technic of the 
procedure consists in placing the patient in the dorsal position 
and exposing the tumor (after thorough asepsis) with the Ede- 
bohls speculum or with retractors. The growth is seized with a 
strong vulsellum forceps, preferably four-bladed, and turned 
upon its axis until the pedicle of the tumor is twisted off. When 
the strong vulsellum forceps are not at hand, the same purpose 
can be accomplished by seizing the tumor upon opposite sides 
with double tenaculum and rotating it by traction with these 



GENITAL TUMORS. 



651 



instruments. When the tumor has not been extruded from the 
cervix, the os can be enlarged by a bilateral incision until the 
intra -uterine tumor is exposed, when it can be removed, if the 
tumor is pedunculated, in the manner described. 

(6) Incision of the Pedicle. — When the tumor has been ex- 
truded from the uterine cavity, it may be seized and dragged 
upon with a pair of forceps until the finger can be passed over 
it as a guide, when with a pair of scissors (Fig. 468) the pedicle 




Fig. 469. — Enucleation of Tumor through the Vagina. 



can be cut ; or the intra-uterine tumor can be rendered accessible 
by dilatation with tents, or through bilateral incision of the 
cervix. The employment of the wire ecraseur or the galvano- 
cautery wire is by some advocated for the cutting of the pedicle, 
but any hemorrhage likely to occur can be controlled by gauze 
packing, and the procedure, outside of the possibility of lessened 
danger from hemorrhage, affords no advantage which will com- 



652 



GYNECOLOGY 




pensate for the extra loss of time. In all these operations rigid 
asepsis must be practised. 

(c) Enucleation. — Enucleation was first practised upon sub- 
mucous fibroid growths of the sessile variety. Here, when the 
uterus is dilated, or after its dilatation, the tumor is exposed, 
seized with a pair of forceps, drawn upon, and, with the finger or 
a blunt dissector, the attachment to the uterus is broken and 
the tumor removed. Thomas employed a serrated spoon which 

hugged closely to the 
surface of the tumor 
and pushed away the 
uterine wall ( Fig. 
469). This spoon, 
however, is not with- 
out danger in cases 
in which the uterine 
wall overlying the 
tumor is thin. The 
enucleation can be 
as readily accom- 
plished with a blunt 
dissector. The tu- 
mor should be rolled 
about during the 
procedure so that 
the surface to be 
separated is con- 
stantly under obser- 
vation. When the 
tumor for enuclea- 
tion is within the 
body of the uterus, 
the finger should be 
used as a guide. In- 
terstitial tumors may 
also be removed in a 
similar way. If nec- 
essary, the cervix as 
a preliminary may be 
split by a bilateral incision through the internal os. An inter- 
stitial tumor of the anterior wall may be made accessible by a 
vertical incision through the anterior lip until the base of the 
tumor is exposed, when it is seized and the tissue bluntly dis- 
sected away from it (Fig. 470). Occasionally, when the cervix 
is undilated and the tumor is in the anterior wall, it may be 
exposed by a transverse incision above the cervix, and subse- 





Fig. 470. — Interstitial Tumor Exposed by Vertical 
Incision of the Anterior Lip. 



GENITAL TUMORS. 



653 



quently by a vertical cut at right angles to the former (Fig. 471) ; 
the flaps are turned back, after which the tumor is enucleated. 
When necessary, the bladder should be dissected from the ante- 




Fig. 471. — Myoma of Anterior Wall Exposed by Transverse and Vertical 

Incision. 



654 



GYNECOLOGY. 



rior surface of the uterus until the peritoneum is reached, and 
the latter can be opened. Retro-uterine tumors are made acces- 
sible through a posterior vaginal incision, which will permit the 
fundus to be rotated backward. Through this opening the enu- 
cleation is accomplished and the line of incision carefully closed 

by sutures before the 
organ is returned to 
its normal position 
(Fig. 472). 

(d) Morcellement. 
— Not infrequently, 
as we proceed in the 
enucleation of these 
growths, it will be 
found that a tumor 
is so large we are un- 
able to complete our 
enucleation or to 
deliver the tumor 
through the vagina. 
In such cases the 
tumor may be re- 
duced in size by the 
process described by 
the French as mor- 
cellement, which con- 
sists in cutting out 
sections of the mass 
with scissors or knife, 
and working up on 
one side until the 
tumor can be drawn 
down and the re- 
maining portion com- 
pletely enucleated. 
It frequently can be 
accomplished by dividing the tumor into halves, quartering it, or 
cutting off small sections of the accessible portions with scissors 
or knife until the entire mass is removed. 

The principle of morcellement is applied to the removal of 
the uterus as well as to extirpation of morbid growths. The 
object is to insure the collapse of the organ until it can readily 
pass through the vagina. It consists in splitting the cervix by 
vertical incision, then removing wedge-shaped masses from each 
side. Avoid nearer approach than one-half inch to the lateral 
surfaces of the uterus. During the procedure the parts are made 




Fig. 472. 



-Myoma of Posterior Wall Exposed by 
. Retro-uterine Incision. 



GENITAL TUMORS. 



655 



tense by traction upon the mass with a double tenaculum (Fig. 
473). Care must be exercised to secure a new grip upon the 
remaining portion before any piece is excised. Upon the com- 
pletion of the delivery of the uterus, the hemostasis is accom- 
plished as in hysterectomy, which will be described later. After 
the removal of the growth by enucleation, there will remain a 
considerable cavity, which is lined by tissue of low vitality. 
This should be thoroughly cleansed and loosely packed with 
iodoform gauze, and the patient watched that no renewal of 




Fig. 473. — Removal of Myoma by Morcellement. 

bleeding occurs. The gauze packing prevents the accumulation 
of blood in the uterine cavity, keeps the surfaces apart, promotes 
the sealing of the surfaces by plastic exudate, and, by its presence 
as a foreign body, favors contraction of the remaining portion 
of the uterus. At the end of three days the gauze should be 
removed, the cavity thoroughly irrigated, and the uterus re- 
packed, or a drainage-tube should be inserted, through which 
irrigation can subsequently be practised. When the cervix has 



A>'.A*.t*i~.;>^ 



656 GYNECOLOGY. 

been incised, the wound should be sutured as in an operation 
for lacerated cervix. All incisions, whether bilateral, through the 
anterior lip, or in the wall of the uterus, should be closed by 
suture. 

538. (5) Ligation of the Vessels. — The usual observation that 
myomata decrease in size with the cessation of the periodic con- 
gestion of the uterus at the establishment of the menopause 
induced Gottschalk and Martin to endeavor to decrease the 
blood-supply to such growths and thus avoid the necessity for 
sacrificing the function of procreation. Gottschalk was the 
pioneer in vaginal operations for this special purpose. He limits 
the operation to extraperitoneal tumors, and in seven years 
found but twenty cases in which it was applicable. Of sixteen 
of these, which continued under observation, decrease in pain and 
hemorrhage was experienced by the majority. In a few the 
good results were delayed. The treatment is as follows: The 
patient is placed in the lithotomy position, the uterus explored, 
and any submucous myomata removed, followed by cure ting as 
a routine measure. A circular incision in front of the cervix is 
prolonged as far as its posterior surface. The bladder is bluntly 
dissected from the uterus and broad ligaments and the vaginal 
mucosa loosened upon each side posterior to the broad ligament. 
The uterine artery and its branches are palpated and secured 
by three silk ligatures upon each side, which are cut short and 
buried by vaginal suture of the mucosa. The operation is fol- 
lowed by severe pains, and a few days later by a cast of the 
endometrium. In but three instances did the first menstruation 
occur at the normal period. Franklin Martin pursued the fol- 
lowing course: With the patient in the lithotomy position he 
dilated, cureted, irrigated the uterus with i : 1000 bichlorid 
solution, and loosely packed it with iodoform gauze. He pulled 
the cervix to one side, made a lateral curvilinear incision over 
each uterine artery, and pulled the bladder away from the ante- 
rior surface of the broad ligaments for over two inches, while the 
latter were partially isolated upon their posterior surfaces. The 
vessels were recognized and guarded by the finger, a ligature was 
passed upon each side, and the ends were cut short. Care had 
to be exercised that a ureter was not included in the ligature. 
He advised that in large tumors the broad ligament should still 
further be spread out and the ovarian artery upon one side 
seized and ligated. The ligated tissue was buried by suturing 
the vaginal mucosa, and the vagina was loosely packed with 
iodoform gauze. Both the vaginal and uterine packing w^ere 
removed at the end of two days and bichlorid douches were 
subsequently employed. This confines the future blood supply 
of the tumor to one ovarian artery. Martin found that this 



GENITAL TUMORS. 657 

plan of treatment resulted in arrest of hemorrhage and decrease 
in the size of the growth. The main objection to this plan of 
treatment is the possibility that in the ligation too much of 
the supply of blood may be cut off, and cause a loss of vitality 
and subsequent necrosis of the growth, which will greatly increase 
the danger to the patient. 

539. (6) Hysterectomy. — Removal of the uterus with the 
offending growths can be done with advantage through the 
vagina when the latter is large and roomy and the uterus is 
not too large and freely movable. The operation should not 
be considered when the growth extends higher than midway 
to the umbilicus, or when the broad ligaments are occupied by 
growths. There are two principal methods of operating: (i) The 
removal of the uterus without section, and (2) division of the 
organ in order to reduce its bulk. The first procedure bears the 
name of Pean. His technic is as follows : The patient is placed 
in the lithotomy position, the cervix exposed with perineal and 
lateral retractors, seized with strong forceps, and a circular or 
oval incision carried through the vaginal mucosa nearer the os 
in front than behind. The finger or a blunt instrument separates 
the bladder from the uterus and broad ligaments. This procedure 
pushes the ureters out of the way. The posterior fornix, or 
Douglas' pouch, is opened in the same way. Freeing the uterus 
before and behind leaves it attached only by the broad ligaments. 
With the finger as a guide, a needle is made to transfix the 
broad ligament at about one -third its height and carry a ligature 
upon its withdrawal. The ligature is tied and the portion of 
structure under its control cut. Its repetition upon the opposite 
side permits the uterus to be drawn down, when the second 
series of sutures can be employed. This course soon permits 
the fundus to appear at the vulva, accompanied by the tubes 
and ovaries. When the uterus is removed, the ligatures upon 
both sides are left long, all bleeding vessels are secured, and the 
anterior and posterior flaps united by suture, securing them at 
either angle above the cut ends of the tubes, when the latter 
have been left. The ligatures are now cut short and the vagina 
loosely packed with gauze. By the second method, with section 
of the uterus, Landau, after exposing the cervix as described in 
the former operation, seizes it with a pair of vulsellum forceps 
at either angle of the os. The incisions of the vagina and of 
the bladder are accomplished as already described, when the 
anterior wall of the uterus is split in the median line with scissors, 
one blade of which enters the cervical canal, while steady traction 
is kept up upon the cervix. As the entire exposed surface is 
split, the finger is introduced and the bladder pushed awav until 
42 



658 GYNECOLOGY. 

the fundus appears. A fresh grip of the forceps is taken upon 
the sides of the incision; the splitting may be carried over the 
fundus and down from the posterior surface until the uterus is 
divided into two portions. If the uterus is still too large for 
delivery, it can be still further divided or the growths may be 
enucleated. The broad ligament can be ligated from above 
downward or from below upward; clamps may be employed, 
though they are not secure. Schauta lost seven patients out of 
forty from the use of clamps. The most of the deaths were due 
to secondary hemorrhage following the removal of the clamps. 
The clamped portion of the ligament will become necrotic and 
may greatly delay convalescence. The wound is treated as 
in the previous procedure. Doyen modifies this operation 
by first opening the Douglas pouch and exploring the pelvic 
cavity. He next incises the anterior fornix, separates the blad- 
der, and crushes the lower and middle third of the broad ligament 
with a special angiotribe. The uterus is drawn down, anterior 
hemisection is performed by a median or V-shaped incision, and 
the fundus is drawn downward and forward. Pressure forceps 
are then applied to each broad ligament and the uterus removed. 
The upper part of the ligaments is crushed and tied with a 
silk ligature in the groove made by the angiotribe. The remain- 
ing portion of the wound is closed with catgut sutures. Should 
the uterus be too large, it can be reduced in size by morcellement, 
'described in Section 537. Bishop cites eight hundred and thirty- 
six cases of vaginal hysterectomy with twenty-nine deaths, a 
mortality of 3.4 per cent. Some operators pride themselves on 
being able to remove per vaginam growths which extend to the 
umbilicus, but such a course is attended with so much increase 
of danger as to render it an unjustifiable method of procedure. 

Abdominal Route. 

540. (7) Castration. — ^As early as 1872 Hegar advocated the 
removal of the ovaries to establish premature menopause in order 
to accomplish reduction in the size of fibroid growths. This pro- 
cedure was devised in recognition of the fact that fibroid tumors 
decrease in size with the establishment of the climacteric. The 
operation consists in the removal of the ovaries and tubes or the 
performance of oophorectomy. It was found, however, that the 
removal of these organs was not infrequently attended with great 
difficulty, as the size of the growth led to a very vascular con- 
dition of the broad ligaments, and often the ovary was spread 
out upon the surface of the tumor, which rendered its enucleation 
and removal exceedingly difficult ; sometimes the tumor rotated 
in such a way as to carry one ovary posterior, rendering it abso- 
lutely inaccessible without reduction of the size of the tumor. 



GENITAL TUMORS. 659 

Moreover, the ovary might be wedged between two multinodular 
growths, whence it could not be removed without injury to both. 
The procedure, unfortunately, was not always successful, as, 
indeed, many patients who were not victims of fibroid growth 
continued to menstruate or to have a bloody discharge subsequent 
to the removal of both ovaries. This is more probably due to 
the fact that the ovarian stroma extends along the course of the 
ovarian ligament, and the removal of the mass in the ordinary 
method of procedure did not remove the entire ovarian structure. 
So long as any portion of it remained, to mature and throw off 
ova, just so long would bleeding from the uterus occur. Tait 
advised the entire removal of the Fallopian tubes as a sure 
method of establishing the climacteric, attributing the influence 
dominating menstruation to these organs. The advantage of this 
suggestion doubtless was that the ligature w^as carried deeper 
and the ovarian artery ligated, which had escaped in a more 
superficial ligation. To insure the ligation of the artery it is 
generally recommended that the ligature should be placed suffi- 
ciently deep to include the round ligament. The advantage of 
castration is that in typical cases it can be done in a very few 
minutes, and with very slight danger; but, unfortunately, in 
large fibroid growths the ovaries are not always typically situated. 
In every such operation, then, the first consideration should be 
to examine carefully the situation of the ovaries and the relation 
to the growth, and see whether both can be thoroughly removed. 
The removal of one would be powerless to exercise any influence 
on the progress of the growth or the correction of its abnormal 
symptoms. Occasionally, the tumor causes torsion of the uterus 
by which one ovary is moved toward the front, and the other 
behind the tumor in such a situation that it can not be reached ; 
or, as noted, the ovary can be so intimately connected with the 
surface of the tumor that any attempt to enucleate or remove it 
would be attended with more serious hemorrhage than would be 
occasioned by the removal of the growth. Another objection to 
the operation is that it does not always control the hemorrhage. 
In the performance of the operation it is absolutely necessary that 
every portion of both ovaries should be removed. The smallest 
amount of ovarian tissue remaining insures the continuation of 
the hemorrhage. When the fibroid is large, the entire removal 
is frequently attended with the greatest difficulty, as the adherent 
ovarian stroma can not be readily separated from the surface 
of the tumor. The operation is still further complicated by the 
existence of tubal diseases, such as pyosalpinx, in which extensive 
adhesions bind together the ovaries, tubes, and tumor in one 
mass, so that castration will be attended with greater obstacles 
and danger than Avould be the removal of the uterus and ovaries. 



660 GYNECOLOGY. 

The operation should not be considered in cases of pure sub- 
mucous myoma or in cystic degeneration of the fibroma. In 
pedunculated subserous and adherent tumors, and in very large 
interstitial growths, it is also contraindicated. In a freely mova- 
ble uterus, in which the cervix can be readily reached, the opera- 
tion affords no advantages over supravaginal amputation. Cas- 
tration has a further disadvantage in not infrequently producing 
vasomotor symptoms, such as congestion, sweatings, hot flashes, 
pain in the head and sacrum. These symptoms are worse in 
the young than in those who are near the climacteric. Other 
symptoms are rather more rare, as, obstinate vertigo, profuse 
leukorrhea, cardialgia, and occasionally vicarious bleeding. 

541. (8) Ligation of the Vessels. — The operation of castration 
having demonstrated the beneficial influence of ligation of the 
ovarian arteries, it was a very natural step to proceed to ligation 
of these vessels through the abdominal incision in preference to 
the more radical operations of partial or complete hysterectomy. 
Hofmeier reported a case of Schroder's in which extirpation of 
the myoma seemed impossible, and where, in order to decrease 
the size of the tumor, the lateral and median vessels of the 
ovary were tied, with good result. Antal, at an earlier date, 
after ligation of the vessels observed an atrophy of the ovary, 
and, in place of castration, thereafter incidentally employed the 
mere ligation of the vessels in order to affect the function of the 
ovaries. Rydygier tied all six uterine arteries of a patient on 
the 27th of June, 1889. The spermatic arteries were ligated; 
then, after splitting the peritoneum near the cervix uteri, the 
uterine arteries were tied; and, finally, a ligature was placed 
about each round ligament. At the end of four months the 
tumor had decreased. to three-fourths its former circumference; 
but after a year hemorrhage, which had completely ceased, re- 
appeared in a stronger degree, and the patient perished from 
marked anemia before radical operation could be performed. 
Byron Robinson has advocated the ligation of both ovarian 
arteries and the upper part of the uterine artery at the side of 
the uterus. This procedure is more effective in the smaller 
growths, and where hemorrhage is a marked symptom. 

542. (9) Myomectomy. — In more or less pedunculated sub- 
peritoneal fibroids there should be no question as to the ad- 
visability of myomectomy. The operation consists, when the 
pedicle is small, in cutting through it with scissors or knife and 
uniting the edges of the cut surface with sutures so deeply 
placed as to make sufficient pressure to control the bleeding. 
(Fig. 474.) When the pedicle is not large, its peritoneal covering 
should be cut through by the circular incision, turned down like 
a cuff, and the base of the pedicle ligated with chromic catgut 



GENITAL TUMORS. 



661 



and the tumor cut away, after which the peritoneal cuff can be 
united over the stump. In larger pedicles the operation consists 
in making peritoneal and muscle flaps, which can be brought 
together. In this way a single growth or a number of growths 
may be removed, leaving a normal uterus, and the ovaries and 
tubes undisturbed. 

543. (10) Enucleation. — The ease with which smaller fibroid 
growths can be enucleated from their beds has led to the practice, 
by Martin and others, of shelling out interstitial fibroid growths 
from the uterine wall, leaving the uterus in place. (Fig. 475-) 
The procedure is performed as follows: The uterus is raised up, 
the position of the gro^\i:hs determined, and an incision made over 
the more prominent growth in a vertical direction in order to 



^:^ 




Fi-. 



474- 



-Abdominal Alvomectoniv 



injure as few vessels as possible. The incision is made into the 
uterine wall and through the capsule, and the tumor is exposed. 
The tumor is then seized with a double tenaculum and drawn up, 
while with a blunt dissector the tissues are pushed off and the 
enucleation is accomplished. The removal of the tumor is fol- 
lowed by firmly packing a gauze pad into its cavity. If large 
vessels bleed, these should be seized and controlled with pressure 
forceps. The wall is still further investigated, and, when possi- 
ble, other fibroid growths situated within it should be brought 
through the first incision. This, in some cases, however, may 
involve more extensive mutilation of the uterus than would a 
separate incision over the mass. 



662 GYNECOLOGY. 

The advocates of this procedtire generally limit it to the cases 
in which but a few growths are found in the uterine wall, and it 
was formerly particularly directed that the uterine cavity should 
not be opened. When we consider the investigations, however, 
of Menge and Kronig, which demonstrate that the uterine cavity 
is free from pathogenic germs, there should be no hesitancy in 
opening it, if necessary, to remove growths. In one patient I 
thus enucleated thirteen fibroids from the wall of the uterus, 
five of which were removed from the uterine cavity. After the 
operation the patient recovered without a single abnormal symp- 
tom. From another woman nine growths were removed. In 
another woman (unmarried) twenty growths were enucleated. 
What remained of the uterus was pretty well riddled, but it 



^^^^B'.. 





Fig. 475. — Abdominal Enucleation of Myomata and Method of Closing the 

Uterine Wound. 

was sutured together and the patient completely recovered. 
In an unmarried woman nine growths were removed, five of 
them from the anterior wall. The loose tissue, being of low 
vitality, subsequently became necrotic, and in the sixth week 
after the operation this was withdrawn through a sinus in the 
abdominal wound ; convalescence subsequently was rapid. From 
an unmarried woman, a fibroid, which projected into the cavity 
of the uterus and had filled it up so that the tumor could be 
touched through the cervix, was enucleated through the ab- 
dominal cavity by posterior uterine incision. A gauze drain was 
passed through the cervix and the uterus closed over it. The 
patient recovered. 



GENITAL TUMORS. 663 

After the enucleation of growths the wounds in the uterus 
should be carefully sutured by deep and superficial layers of 
chromicized catgut, exercising the precaution to include and 
secure with the suture any large vessels in the wall which may 
bleed, and by the superficial suture to bring a good portion of 
the peritoneal surface of the uterus in apposition. Before the 
abdomen is closed all the wounds must be thoroughly inspected 
to see that hemorrhage is completely controlled. Should there be 
a tendency to excessive bleeding, it would be better to ligate 
the ovarian arteries as an additional safeguard. This operation 
is not suitable for very large growths in which the uterus is 
very extensively mutilated, or where the tumors are situated 
laterally and involve to a greater or less degree the Fallopian 
tube. In enucleation of intraligamentary growths the broad 
ligament is split, in order to expose the growth. In these cases 
care must be exercised that the ureter has not been displaced 
upward by the tumor. It is important, also, to avoid injury to 
the ureter or its ligation in the subsequent closing of the broad 
ligament. 

544. (11) Partial Hysterectomy, or Supravaginal Amputation 
of the Uterus. — This was the earliest abdominal operation per- 
formed for the removal of myomatous growths, and the earlier 
operations were cases of mistaken diagnosis, the procedure having 
been undertaken for the removal of ovarian tumors. The first 
deliberate operation seems to have been performed by Burnham, 
of Lowell, in 1853, i^ which the patient recovered. A large 
proportion of the earlier operations were unsuccessful; the diffi- 
culty in controlling hemorrhage from the elastic stump rendered 
its intraperitoneal treatment exceedingly dangerous, so that the 
procedure was practised of treating the stump extraperitoneally. 
The first to form a systematic method of operation was Koberle, 
of Strasburg. The method of performing the operation was as. 
follows: The patient was placed in the dorsal position, and a. 
long abdominal incision made in the median line, through which 
the uterus and tumors were delivered. The peritoneum above 
the bladder was incised and the latter stripped down, an elastic 
ligature or serrenoeud was placed about the cervix as low as 
possible, and pins were passed through it above the serrenoeud. 
The uterus and tumors were cut away sufficiently above the pins 
to prevent the traction of the stump from the grip of the instru- 
ment, the abdominal wound was closed down to the stump, 
while the latter was subjected to cauterization, and an applica- 
tion of persulphate of iron or tannin made to its raw surface 
to secure mummification. By some operators the parietal peri- 
toneum was fastened to the peritoneal covering of the stump by 
a continuous catgut suture. This procedure was done to promote 



664 GYNECOLOGY. 

the rapid union of the peritoneal surfaces and thus preclude the 
possibility of the discharges from the sloughing stump gravitating 
back into the peritoneal cavity. 

Occasionally, under this plan of treatment, the stump would 
become dry .and gradually be thrown off without suppuration. 
It resulted, however, in an excavation, by the retraction of the 
stump, which had to close by a process of granulation, making 
convalescence prolonged. Often it was difficult to prevent the 
putrefactive changes taking place and resulting suppuration. The 
weakened abdomen favored the subsequent development of ven- 
tral hernia. Weill gives the mortality in three hundred and 
ninety-two cases as 18.6 per cent. Hauck's latest list of three 
hundred and eight cases gives a mortality of 8.7 per cent. The 
difficulty in maintaining asepsis, the delayed convalescence, the 
weakened abdominal wall, led to the study of methods by which 
the stump could be treated within the peritoneal cavity. One of 
the earliest operators to attempt the intraperitoneal treatment 
was Schroder, who published in 1880 an account of his cases. 
He opened the abdomen by a median incision, ligated that 
portion of the broad ligament containing the spermatic arteries 
with two ligatures, and cut between them. A similar course was 
pursued with the round ligaments. The stump, consisting of 
the cervix, was constricted by a rubber ligature, the mass cut 
away above the ligature, the stump caught with the vulsellum 
forceps before the division was completed, and the cervical cavity 
cauterized with a 10 per cent, solution of carbolic acid. The 
divided surfaces were united near to the mucous membrane with 
sutures ; this covered with several rows of suture and, finally, the 
peritoneum was sutured over the stump, after which the rubber 
ligature was removed. He employed carbolized silk, and later 
juniper catgut, for sutures. Other operators have modified this 
procedure, as Zweifel, with partition ligature, and H. 0. Marcy, 
with cobbler suture. Gow makes the following modifications: 
After delivery of the tumor through a median abdominal incision, 
he ligates each round ligament on a level with the internal os, 
marks out an anterior peritoneal flap, and divides the round liga- 
ment and the anterior portion of the broad ligament between 
the uterus and the ligatures with scissors, carrying the incision 
toward the middle of the Fallopian tubes. The anterior flap is 
stripped down, the ovarian vessels and the Fallopian tubes 
enucleated and tied so that at least one ovary is left. The broad 
ligaments are divided on the uterine side of the ligature, and 
bleeding from vessels connected with this portion may be tem- 
porarily controlled by clamps. He then marks out a posterior 
flap and dissects it downward for a short distance, seizes the 
uterine arteries with pressure forceps at the level of the os inter- 



GENITAL TUMORS. 665 

num, cuts the tumor away with a knife, seizes and draws up 
the stump with vulsellum forceps, ties the uterine arteries, inserts 
a precautionary ligature by thrusting needles armed with silk 
through the stump from before backward, avoiding the peri- 
toneum, so as to include the outer portion of the stump. This, 
done upon both sides, controls oozing or spurting from vessels 
which may have been given off obliquely. The bleeding area 
may also be encircled with a ligature passed by a Hagedorn 
needle. Two antero-posterior sutures are introduced through the 
muscular surface of the stump, avoiding the peritoneum, the 
raw surfaces, as a rule, are sewed together, the peritoneal flaps 
united, the peritoneum cleansed, and the abdomen closed. Baer 
modifies this operation. His course is as follows : The patient is 
placed in the Trendelenburg posture, and after separation of the 
adhesions the tumor and uterus are delivered through an ab- 
dominal incision, gauze is placed front and back, each broad 
ligament is transfixed by a single silk ligature, which, when tied, 
controls the ovarian arteries and veins. The ligated parts are 
then severed external to the tube and ovary, incision being 
carried close to the cervix. The peritoneal reflection anterior 
to the uterus is cut through with scissors, the bladder stripped 
down with the handle of the scalpel, the uterine artery tied 
close to the cervix on each side, and the cervix amputated just 
above the vaginal attachment. A small posterior fold is formed 
by stripping up the peritoneum while the amputation is made. 
The stump is now held in the grasp of tenaculum forceps. When 
the main arterial branches have been properly ligated, the raw 
end of the cervix will remain dry (Fig. 476). When all bleeding 
has been controlled, the peritoneal folds are loosely adjusted 
over the stump with Lembert sutures and the abdominal incision 
is closed (Fig. 477). Difficulties have occasionally been found in 
this operation from pus or exudates forming above the stump 
beneath the peritoneal covering (Fig. 478). Le Bee, after ab- 
dominal section, draws out the uterus and fibroids, ligates the 
broad ligament with a double ligature and severs it between 
the ligatures. The round ligaments are ligated separately and 
the bladder with the peritoneal flap dissected down into the 
vagina. The tumor may be decreased in size by throwing a 
rubber ligature around the cervix and cutting away the mass 
above, or the tumor can be drawn over the pubes, a long curved 
forceps inserted into the vagina so that, when opened two or 
three centimeters, the posterior fornix is stretched. A small 
incision is made into the pouch of Douglas, and widened by 
opening the forceps. The tumor is drawn back and forceps are 
introduced so as to protrude against the anterior fornix, when 
the latter is treated in the same wav. Care must be exercised, 



666 



GYNECOLOGY. 



however, not to rotate the tumor to one side and thus injure 
the large uterine veins. One end of a long silk thread is seized 
by forceps, carried into the vagina, and brought up again through 
the opening in Douglas' pouch. Another thread is similarly 
applied on the opposite side. Both are tied, thus controlling the 
uterine arteries. The tumor is removed horizontally just above 
the ligatures, and only leaves a pedicle. This pedicle is split 
in the median line and as much cut away from each side as 






Fig. 476. — Supravaginal Removal of Myomatous Uterus. 



possible, only leaving sufficient to hold the ligatures. The long 
ends of these are seized with the forceps and drawn downward, 
the peritoneal flaps sutured together with catgut, and the abdo- 
men closed. The Pryor-Kelly modification of the operation con- 
sists in the ligation of the ovarian vessel and round ligament 
and the division of the ligament upon one side. An anterior 
peritoneal flap is formed and the peritoneum and bladder stripped 
down. This exposes the uterine artery and veins, which are 



GENITAL TUMORS. 



667 



ligated by a ligature carried with a curved needle beneath them 
close to the side of the uterus, the organ is drawn to the opposite 
side, and the uterine vessels are divided. The uterus is cut 
across just above the vaginal junction. A pad of gauze is placed 
beneath the upper cut surface to prevent the intrauterine dis- 
charges from escaping on to the wound while the canal below 
is wiped out. When near the opposite edge of the cervix, the 
incision is carried up one to two centimeters so as to leave a 
thin shell of cervical tissue and to expose the uterine vessels at 
a higher level, where they can be more easily tied and with 




Fig. 477. — Cervix Cut Across Preliminary to the Complete Ligation of One 

Ligament. 



less risk of including the ureter. The uterine vessels are clamped 
and divided, the uterus is rolled still further over, the round 
ligament clamped and cut through. With still more traction, the 
ovarian vessels come into view, when they are clamped and cut 
and the whole mass becomes free. All clamped vessels are then 
tied. Kelly ties all important vessels twice, once during the 
enucleation and again after it is completed. After control of the 
hemorrhage, the stump is closed over the cervical canal by three 
to five catgut sutures. These sutures do not include the mucous 



668 



GYNECOLOGY. 



membrane, the anterior peritoneal flap is drawn over the stump 
and united by continuous catgut suture to the posterior peri- 
toneum. Where a large space has been left in the cellular tissue, 
it is advisable to unite the peritoneum with interrupted or mat- 
tress sutures, so that blood can run into the peritoneum and be 
absorbed instead of forming a hematocele. Bishop modifies the 
operation by removing the cervix entire. When the broad liga- 
ment is ligated, having reached the stage of ligation of the 
uterine artery upon one side, instead of cutting across the cervix 
he has an assistant push up the lateral culdesac of the vagina 
and cuts down upon it, and thus enters the vagina. With the 
scissors the vaginal wall is then cut through entirely around the 
cervix, which is bodily lifted up with the rest of the uterus and 




Fig. 478. — Stump Covered with Peritoneum. 



rolled over toward the opposite side. The cervix is seized with 
strong forceps and pulled up against the free surface of the 
uterus. It has been previously plugged and, consequently, gives 
no trouble from the discharges. This procedure affords a ready 
method of enucleating intraligamentary fibroids, especially if 
they are situated upon one side of the abdomen. The entire 
removal of the uterus has another advantage, that there is no 
obstacle to drainage from the pelvis. He draws down into the 
wound a roll of iodoform gauze and closes the peritoneum over 
it. The abdomen is closed without drainage. E. C. Dudley 
claims that the union of the peritoneal fiaps by transverse sutures 
permits the pelvic fioor to sag down. Therefore he advocates the 
union of these surfaces by an antero-posterior line of suture. 
Where the cervix is left, a flap is made on each side. These 



GENITAL TUMORS. 669 

are united, and over them the peritoneal flaps are drawn and 
secured by an antero-posterior line of sutures. The operative 
procedure just described affords a ready method for dealing with 
those intraligamentary tumors which occupy only one side of the 
pelvis, but where we have the uterus filled up with fibroid growths 
and extending into the broad ligaments upon both sides, and 
we can not reach Douglas' pouch posteriorly, the problem for 
removal seems a most complicated one. The operation in these 
cases, however, can be very expeditiously performed by making 
a vertical section through the uterus and tumor from the fundus 
downward, dragging the masses to either side as the incision is 
made. The intestines, of course, are held back by gauze intro- 
duced behind the tumor, while the bladder is rendered visible 
as we proceed in the division. In this w^ay the entire uterus 
may be split down to and through the cervix, or, if preferred, 
each side may be cut through at the vagino-uterine junction, 
leaving the cervix as a simple stump. As the low^er portion is 
drawn upward, the uterine artery becomes visible. This is 
secured with clamp forceps. Further traction upon the mass 
rolls out the fibroid growths from the broad ligaments, and later 
renders visible the ovarian artery,' which is also secured. The 
broad ligament is clamped external to the ovary and tube, and 
the mass removed. A similar course upon the opposite side 
leaves us with the uterine and ovarian vessels clamped ready for 
the application of the ligature. 

The remaining steps of the operation may be completed as 
described in the previous operative procedures. 

545. (12) Panhysterectomy, or total extirpation of the uterus, 
is a preferable procedure in those cases in which the cervix has 
been largely taken up by the extension of the growth, or when 
it has undergone extensive disease. This operation may be per- 
formed by a number of methods : 

I. The method of A. Martin, of Berlin: With the patient in 
the dorsal position, through a large median incision the tumor 
is drawn out, and, if necessary, can be made more movable by 
the enucleation of masses after the capsule has been split. The 
infundibulopelvic ligament is ligated and the broad ligament 
divided until the cervix is reached, beginning usually upon the 
left side, but in all gases on that in which the procedure would 
be most complicated. Having completed ligating one side before 
attacking the other, a pair of clamp forceps is applied on the 
uterine side of the line of ligature. The broad ligament is then 
divided between the forceps and ligatures to the cervix. The 
uterus can then be brought over the symphysis pubis, the pos- 
terior fornix is cut through by scissors, close to the cervix, and 
the two edges of the wound united bv sutures. Sometimes bent 



670 ■ GYNECOLOGY. 

forceps are passed and from the vagina made to tear through 
the posterior fornix into Douglas' pouch, and by separating the 
blades the structures are torn with less danger of bleeding. A 
ligature is passed around the lower attachment of the broad 
ligament on the one side, which is then divided. The os is 
seized with a pair of forceps, which both closes the cervical canal 
and draws the cervix upward and backward into the peritoneal 
cavity. The other side of the broad ligament can now be secured 
in a similar manner. The anterior vaginal fornix is then divided 
and the firmer bands of connective tissue will meet in this situa- 
tion. When these are cut through, the cervix separates easily 
from the bladder. Bleeding vessels are secured with the ends 
of the ligatures drawn down into the vagina. The peritoneum 
is united by transverse sutures over the vaginal wound and the 
abdominal wound closed without drainage. 

II. The Method of Christopher Martin, of Birmingham: With 
the patient in the dorsal position, he delivers the tumor through 
a median incision and packs gauze pads above and below. A 
double thread is passed through the broad ligament at the 
junction of its upper and middle thirds, and midway between 
the uterus and pelvic wall. These two sutures do not interlock. 
By pulling them forcibly inward and outward, the punctured 
aperture is torn with a transverse slit and the two ligatures are 
tied as far apart as possible and the intervening broad ligament 
divided. The same process is repeated on the opposite side. 
He prefers, where possible, to leave one ovary and tube. The 
other is removed with the uterus. A second ligature is passed 
through the broad ligament about the level of the internal os 
and nearer to the uterus than the first one. The aperture punc- 
ture is again stretched, when the ligature is tied as far apart 
as possible and the intervening tissue divided. The bladder is 
then separated from the anterior surface. He also advises the 
use of the sound in the bladder, to define its upper edge. A 
curved incision, two- thirds of an inch from the upper edge of 
the bladder, is made from one broad ligament to the other, 
and the bladder is stripped down. The surgeon can determine 
when he has reached the vagina by following the tip of a pair 
of forceps pressed into the anterior fornix. The vagina is opened 
upon these with scissors and the opening enlarged. The posterior 
fornix is similarly treated. The ureters, when seen, are pressed 
outward. The uterine arteries now remain to be tied. Ligatures 
are passed through the remaining portion of the broad ligament, 
hugging close to the mucous membrane of the lateral fornix of 
the vagina, and are tied upon either side. The uterus is then 
cut loose, keeping the scissors as far as possible from the two 
lower sutures. The cut edges of the vaginal walls are drawn 



GENITAL TUMORS. 



671 



upward with forceps and carefully inspected. All blood-clots are 
sponged out of the pelvis and all bleeding points ligated. The 
ligatures may be cut short or may be left long, the ends being 
used to draw the stumps into the vagina. The vaginal wound 
is not closed, but is filled with a thick roll of iodoform gauze 
drawn through into the vagina. The abdomen is closed by inter- 
rupted silkworm-gut sutures. The gauze placed in the vagina 
is removed on the fifth or sixth dav. 




Fig. 479.— Panhysterectomy. Doyen's Method. The tumor rolled out, inci- 
sion made from Douglas' pouch into the vagina upon the end of a pair 
of forceps. 



III. Doyen s metJiod: With the patient in the Trendelenburg 
posture, the tumor is lifted out through an abdominal incision 
and drawn forward over the pubes. A long, curved forceps, 
previously passed into the vagina, is made to project into Doug- 
las' pouch, upon which an opening is made into the vaginal 
canal. Through this opening the cervix is seized by the anterior 
lip, if possible, and drawn upward and backward (Fig. 479). 



672 



GYNECOLOGY. 



While held in this position, the entire circumference of the attach- 
ment of the vagina to the cervix is under view and can be divided 
all around by scissors (Fig. 480). The cervix is separated from 
the bladder by traction upward until the peritoneum above the 
bladder is reached, which is broken through and stretched back. 
The broad ligament external to the ovary and tube on the right 
side is clamped and incised with scissors. Clamp forceps are 
then applied to the broad ligament of the opposite side, when 
it likewise is cut through external to the ovary and tube. Fre- 
quently, by this method of procedure, the uterine arteries are 
not injured. The division is so close to the cervix that the main 




Fig. 480. 



-Cervix Separated from the Vagina, and Being Pulled Away from 
the Bladder and Ureters. 



branch is not divided, and it is only the smaller branches that 
are torn, and consequently do not bleed. The pedicles of the 
broad ligaments are crushed with the angiotribe and ligated in 
the groove. The uterine arteries are also ligated and forceps 
removed. The vaginal mucous membrane can be united by two 
or three sutures with the peritoneum. The ends of the ligatures 
on the arteries are drawn down into the vagina, and the pelvic 
peritoneum is united by a purse-string suture across the pelvis, 
so as to invert the stump of the broad ligament below this 
structure. The abdominal wound is closed without drainage. 



GENITAL TUMORS. 673 

Doyen, in his earlier operations, trusted to the angio tribe alone, 
but later applied a catgut ligature in the groove. This procedure 
is preferable. 

IV. Schauta's method: The tumor and uterus are drawn out 
through a median incision and the broad ligament on each side 
divided between clamp forceps. The anterior peritoneum is 
divided and, with the bladder, stripped down to the vagina, 
the tissues are clamped upon each side and the vagina opened 
right and left between the clamps and the uterus. The tumor 
is now held by the anterior and posterior vaginal walls, which 
are secured by curved clamps, and the uterus removed. Liga- 
tures are substituted for the clamps, which are left long and 
employed for vaginal drainage. The abdominal cavity is closed 
by union of the peritoneal folds over the vagina. 

V. Richelot, through an abdominal incision, first separates 
the anterior peritoneal fold and bladder. The uterine arteries 
are found, clamped by forceps, and cut close to the uterus. 
The anterior culdesac is found and opened ; the cervix seized and 
drawn upward and forward. The cervix is separated from the 
vagina by a circular incision and the broad ligaments are separated 
in sections from below upward. This plan affords an effective 
procedure when there are extensive adhesions following disease 
of the appendages. All the clamped vessels are securely ligated 
and the vaginal wound is closed with catgut. 

In difficult cases. Bishop employs what he calls the combined 
method, which may be begun either from below or from above. 
In the former, the patient is placed in the lithotomy position, 
the uterus exposed by retractors, seized and drawn down with 
vulsellum forceps. The cervix is cleansed, packed with gauze, 
and if there is much discharge, the os is closed by a suture. 
A circular or ovoid incision is then carried around the cervix, 
completely dividing the vagina, when, with the finger hooked 
closely to the uterus, the bladder is separated from the anterior 
surface of the uterus and well to either side. In large tumors 
this can not be accomplished to a great extent, but should be 
sufficiently to expose the uterine vessels. Douglas' pouch is 
opened, and, with the one finger behind and the thumb in front, 
the uterine artery should be defined, ligated, and the ligament 
cut as far as the ligation extends. Hemorrhage is carefully con- 
trolled and the vagina loosely packed with gauze. The patient 
is then changed to the Trendelenburg posture and the abdomen 
opened through the rectus sheath of one side. All adhesions to 
omentum and intestine are separated, and, where indicated, 
ligatures applied. A gauze pad is placed over the intestine. 
When the ovaries and tubes are healthy, they are to be left. 
When diseased, part of the ovary at least is retained. One 

43 



674 GYNECOLOGY. 

ligature is made to embrace the ovarian ligament, if the tube 
and the round ligament near the appendages are healthy enough 
to permit of their being retained, and is tied as near to the 
uterus as the retention of the ligature will permit. The ligament 
is cut close to the side of the uterus. The lateral incisions are 
joined by a curved incision anterior to the uterus, about half 
an inch above the line of the bladder, which is stripped down 
until the previous separation has been reached. The uterus is 
now attached only by the central portion of the broad ligament 
upon each side, which is ligated and the uterus cut aw^ay. Bleed- 
ing vessels are ligated and the ligatures cut short, the pelvis 
dried, a roll of gauze pulled through into the vagina, and the 
peritoneal flaps closed over it with a continuous catgut suture. 
All raw edges are carefully inverted into the vagina, so that the 
peritoneal wound is perfectly smooth. Bishop closes the ab- 
dominal wound with catgut for the peritoneum, crin de Florence 
for the aponeurosis, and horsehair for the skin. With the inser- 
tion of the last layer, the skin should be cleansed, dried, and 
painted with celluloidin, which forms an air-tight covering. 

Bouilly preferred to begin from above and finish from below. 
He delivers the tumor through the median abdominal incision 
with the patient in the Trendelenburg posture, divides the 
broad ligament between double ligatures, incises the peritoneum 
in front of the uterus and pushes down the flap with the bladder, 
ligates the broad ligament so as to include the uterine arteries, 
amputates through the cervix, and closes the abdomen. Then, 
with the patient in the lithotomy position, he removes the 
cervix per vaginam, sutures the peritoneal flaps from below, 
and plugs the vagina with gauze. This procedure is particularly 
valuable in a sloughing flbroid which communicates with the 
vagina. 

546. Summary. — An effort has been made to present to the 
student a resume of the various procedures for the treatment of 
myomatous growths of the uterus. It is recognized, however, 
that when he comes to treat a case, he may be doubtful as to 
which method will be applicable to it. I feel it but proper to 
indicate what I believe to be the most justifiable methods of 
procedure. In submucous growths in which hemorrhage is a 
marked factor, the tumor, when accessible, should be removed 
by torsion or excision of the pedicle. If the tumor is still within 
the cavity of the uterus, the cervix may be dilated with laminaria 
tents, and, if suflicient room is not thus secured, the os can 
be split by a lateral or an anterior incision, as may be most 
convenient, and the tumor removed by torsion, by excision of 
its pedicle, or by enucleation. If the tumor is too large to 
permit of its ready extirpation, it should be removed by mor- 



GENITAL TUMORS. 675 

cellation. Vaginal hysterectomy should be confined to growths 
which are not too large to permit of their ready passage through 
the vagina, and yet in which the uterine structure is so taken 
up and involved as to preclude the retention of the healthy 
uterus, or in which the ovaries and tubes are secondarily in- 
volved, precluding the retention of the myomatous uterus. Of 
the abdominal operations named, myomectomy, enucleation of 
the growth, or partial or complete hysterectomy, can be per- 
formed. The principle here should be that no organ should be 
sacrificed the function of which can be maintained, so that when 
the ovaries and tubes are in such a condition as to justify the 
retention of the uterus, myomectomy or enucleation should be 
practised, even though a number of fibroid growths are present. 
When the uterine structure is much involved, or if ovarian, 
uterine, or tubal disease complicates the condition, we are forced 
to resort to either partial or the complete hysterectomy. My 
experience inclines me to advise complete hysterectomy, for the 
retention of the cervix affords no special advantage. Its com- 
plete removal does not add to the difficulty nor prolong the 
operation. It affords better drainage and expedites the recovery 
of the patient. No one operation is applicable to every patient. 
In the majority of cases, the Doyen operation is the most satis- 
factory. When the broad ligaments are shortened by inflamma- 
tion and the pelvis filled up by myomata, the operator may 
be unable to reach the cervix from behind. Then, of course, 
another method of procedure must be chosen. The uterus con- 
taining the growths may be divided by a vertical section, enu- 
cleating portions of the tumor mass, thus decreasing the size 
of the uterus and affording more room for work. Proceeding 
from below upward, intraligamentary growths are shelled out 
without much danger to the ureters and afford better opportunity 
to secure hemostasis. Where access to one side of the pelvis is 
partially barred by infiammatory shortening or the ligament is 
occupied by myomata, the Bishop modification of the Pryor- 
Kelly operation permits ready removal of the uterus and growths. 
547. Accidents during Operation. — -Hemorrhage is an accident 
which is avoidable with careful application of ligatures. Where 
the tissues are ligated en masse, the angiotribe should be em- 
ployed and the compression of the tissue followed by the appli- 
cation of a catgut ligature in the groove. The compression fur- 
nishes a button over which the ligature is unlikely to slip. When 
the cervix is retained, bleeding from the stump is avoided by 
applying ligatures upon each side to control the blood-supply 
from the uterine arteries. One advantage of the entire removal 
of the uterus is that hemorrhage, when it occurs, is at once 
revealed by its discharge from the vagina. Internal hemiorrhage 



676 GYNECOLOGY. 

will be indicated by symptoms of increasing shock, and the 
occurrence of such symptoms should be considered an indication 
for prompt reopening of the wound to secure the open vessel, 
for, should the patient rally from the hemorrhage, the large 
accumulation in contact with the intestine in the weak state of 
the patient endangers her subsequent course, from sepsis. All 
bleeding vessels should be firmly secured before the peritoneal 
wound is closed. Care must be exercised in short broad ligaments 
that the ovarian artery is not retracted behind the peritoneum 
from the grasp of the ligature, there to produce a concealed hem- 
orrhage or thrombus which may become so large as to open into 
the peritoneal cavity. 

Injuries to the Hollow Viscera. — In the injuries to the viscera 
the bladder is most likely to be affected, as it is closely attached 
to the anterior wall of the uterus and cervix. Its relations 
to the uterus and tumor will largely depend upon the situation 
of the growth. One which has originated in the lower part of 
the anterior wall of the uterus may very readily drag up the 
bladder, and cause it to be displaced upward. The bladder 
may be displaced to one side, and not cover the anterior surface 
of the uterus and tumor. This may readily occur because of 
partial torsion of the neck of the uterus or from the size of the 
growth. In one case I incised the bladder when it was displaced 
upward and to the left side, to form a quite distinct tumor 
that did not entirely disappear under the use of the catheter. 
The bladder was accidentally incised in opening the abdomen. 
It was immediately sutured, removed from the surface of the 
growth, and the patient recovered. Inflammatory adhesions 
may bind the bladder to the anterior surface of the tumor, and 
in the subsequent development may drag it so high that it is 
overlooked in the separation of adhesions. In such a way 
I was so unfortunate as to incise the fundus where adhesions 
were extensive, involving both anterior and posterior surfaces. 
In this patient recovery took place after the bladder wound 
was sutured. When the bladder is injured, the wound should 
be closed by sutures at once, whether it occurs upon the peritoneal 
or on the nonperitoneal surface. Precaution should be exercised 
in the use of the sutures that they do not include the vesical 
mucous surface. It is well to have a double row of sutures, 
in order to bring a larger surface of the bladder-wall in apposition, 
and in the subsequent convalescence the bladder should be 
frequently evacuated. When the wound has been extensive, 
it would be preferable to employ a permanent catheter for the 
first week, and for the second week to have the urine drawn 
at frequent intervals. The possibility of displacement of the 



GENITAL TUMORS. 677 

bladder by the growth should always be considered, and care 
should be exercised to avoid its injury. 

Injuries of the Ureter. — The situation of the ureter along- 
side the cervix makes it particularly vulnerable in the removal 
of large fibroid growths, and particularly in those where the 
growth is developed low in the broad ligament, which, in some 
cases, shoves the ureter upward until we find it in the groove 
between the growth and the uterus. In such patients the dis- 
section should be most carefully practised in order to avoid 
injury to the ureter. The Doyen operation lessens the danger 
to both bladder and ureter ; the cervix is pulled away alike from 
the bladder and the ureters. In the intraligamentary variety 
the tumor is dragged away from its relations to the ureter. In 
case of injury, and particularly when the ureter has been cut, 
the proper procedure would be to bring about: First, the an- 
astomosis between the ends of the divided ureter; the union 
can be end-to-end, the cut surfaces being made oblique. An- 
other method is to close the vesical end and make an incision 
at a lower level in the wall, through which the renal end is intro- 
duced and secured by sutures (Fig. 221). Second, its trans- 
plantation into the bladder. In introducing the ureter, it is 
important that it should be anchored in the bladder in such 
a way as to prevent it slipping back or drawing away from 
its attachment to the bladder surface, which would permit the 
urine to escape into the peritoneal cavity (Fig. 220). If the 
union with the bladder is difficult, because the injury of the 
ureter is situated so high that the latter reaches the bladder 
only upon slight stretching, it is well to anchor the bladder 
at a higher level to the side of the pelvis, so that no traction 
shall be made upon the shortened ureter. In those cases in 
which we have a ureter too short to establish an anastomosis 
with the peritoneal end or transplantation into the bladder, 
the following alternative procedures have been suggested : 

Third. — Carry the ureter across and anastomose it with 
the ureter on the opposite side. In a short ureter this may 
be attended with considerable difficulty. We should hesitate 
about imperiling the patient by disturbing the remaining conduit. 

Fourth. — The introduction of the ureter into the correspond- 
ing colon. This operation has not been attended with very 
satisfactory results. The infection and gases from the intestine 
have been known to be carried into the ureter, to cause its in- 
fection as well as that of the pelvis of the kidney. The contact 
of the urine with the intestine is said to cause considerable 
irritation and to produce a marked diarrhea. 

Fifth. — Bring the extremity of the ureter out through the 
abdominal wound or make a fistulous opening to the skin sur- 



678 GYNECOLOGY. 

face. Such a procedure is attended with no little discomfort 
to the patient, as the constant soiling of the person and cloth- 
ing with the urine is very distressing to a cleanly patient and 
annoying to those who have to be associated with her. 

Sixth. — Ligate the ureter and drop it back. This ligation 
should be made by a double ligature, for the reason that, under 
the process of pressure-atrophy, the ligature becomes loosened 
and, when single ligatures are used, the urine escapes into the 
peritoneal cavity, and causes urinary infiltration and septic 
peritonitis. This condition is less likely to occur when a second 
ligature is applied from half an inch to an inch above the first. 
The urine continues to be secreted until the pressure within 
the cavity of the kidney is equal to the blood pressure, when 
the secretion is arrested. In such cases the kidney, unable 
longer to secrete the urine, becomes a useless organ and atrophies, 
while the extra work is taken up by the remaining kidney. 
The result of the procedure, of course, will depend, as it would 
in nephrectomy, upon the condition of the other kidney. 

Serenth .—KemoYdl of the kidney. 

Intestinal Injuries. — Injuries of the intestine are less fre- 
quent. They may occur as a result of extension and firm ad- 
hesions to the surface of the growth. The injury is much more 
likely to take place in the sigmoid fiexure of the descending 
colon and the rectum. As a result of chronic inflammation, 
the adhesions may be very extensive and firm, and lead to the 
injury of the intestine before its possibility could be suspected. 
In all cases of extensive adhesions, after the removal of the 
growth careful examination should be made to ascertain the 
possibility of intestinal injury. Such adhesions may also re- 
sult from complications, such as suppurative disease of the 
tubes, associated with the growth. Very frequently an opening 
will result between a tubal abscess and a knuckle of intestine, 
through which its contents have been discharged. Recently, 
in removing a fibroid growth associated with pelvic suppuration 
I found an opening from a left tubo-ovarian sac in the anterior 
surface of the sigmoid flexure, into which the thumb could 
be introduced. Through this the abscess had partly emptied 
itself at intervals. In closing the wound care should be exer- 
cised to trim the edges of the opening, to remove the tissue 
that has low vitality or has been injured during the process, 
and to bring the surfaces together by a double row of sutures. 
Continuous chromicized catgut suture is a very serviceable one, 
but, as mentioned, the suture should be so introduced as to 
bring extensive surfaces in apposition. The patient should 
subsequently be kept upon an albuminous broth diet, and 
early evacuation of the bowels should be accomplished, afford- 



GENITAL TUMORS. - 679 

ing no opportunity for hard fecal masses to form in this portion 
of the intestine. In closing the wound, in these fistulous cases, 
it is well that gauze packing should be applied and drainage 
practised, for it is always difficult to make certain that all the 
tissue of low vitality has been removed and that a fistulous 
opening may not recur. If the abdominal wound is closed, 
leakage may cause fatal infection of the peritoneal cavity before 
the gravity of the condition is recognized. If a small fistulous 
opening in such a patient occurs, it is preferable to keep the 
wound open and the cavity thoroughly cleaned by frequent 
irrigation, both by the rectum and the abdominal wound, and 
to permit nature an opportunity to close the opening by granu- 
lation. Nature soon shuts off the tract of the general perito- 
neum and prevents the possibility of its infection. To reopen 
such a wound in order to close the fistula increases the danger 
of general infection. Where the intestine is free and unob- 
structed, a fistula will close by granulation, but should the 
intestine be obstructed or kinked below, the latter will not close. 
The effect of a fistula will depend upon its size and position 
in the intestinal tract. Free discharge from the intestine high 
up means that much nutritive fiuid is removed from the pro- 
cesses of absorption. Therefore, a corresponding loss of vitality 
results. A fistula in the large bowel, however, may exert but 
little infiuence upon the general nutrition. 

548. Causes of Death Following Hysterectomy. — The most 
frequent causes of fatal results are hemorrhage, septicemia, 
and shock. Hemorrhage may be the cause of death shortly 
after the operation, from difficulty in controlling the bleeding 
during the procedure, although these cases must necessarily be 
rare ; or it results from the subsequent slipping of a ligature from 
the pedicle mass. Unless the condition is recognized at once, 
the hemorrhage may be immediately fatal. If the enfeebled 
condition of the patient leads to formation of a clot and the 
arrest of bleeding, the large accumulation of blood in the peri- 
toneal cavity may still be a source of danger to the patient, 
through its infection by its relation to the intestine or from 
pathogenic germs which" may have been left in the pelvic cavity. 
In this sense it may furnish the cause for the subsequent death 
of the patient from septicemia. The danger from septicemia 
is greatly increased in those cases in which the operation has 
been difficult, owing to intraligamentary growths, when the 
tissues of the pelvis have been greatly torn during the progress 
of enucleation, or when the tumor is complicated by the presence 
of suppurative processes in the tubes, in the ovaries, or in the 
pelvis. Another prolific source of fatal result is shock. This 
may be incident to severe hemorrhage during the progress of 



680 GYNECOLOGY. 

the operation; to a protracted operation on account of exten- 
sive adhesions, the growth being impacted in the pelvis, or 
from the previous enfeebled condition of the patient. We 
are not always able to account for the marked influence of 
shock. Occasionally, we will find the patient becoming greatly 
shocked almost before the operation is begun, as a result of 
the depressing influence of the anesthetic. This does not seem 
to be wholly dependent upon the condition of the circulation 
or of the renal secretion. Other and less frequent causes of 
fatal termination are embolism, ileus, and tetanus. 

549. After-treatment. — The after-treatment of operations 
for the removal of fibroid growths does not differ in a marked 
degree from that of other abdominal operations. The greater 
injury and the corresponding amount of shock require, of course, 
more careful consideration and attention. When the patient 
has undergone extensive operation, much injury of the pelvis 
has occurred. If drainage is not practised, it is very desirable 
to place the patient in such a position as will promote the drain- 
age from that portion of the pelvis most injured into the general 
peritoneum; so the foot of the bed should be elevated from 
six to eighteen inches. This decreases the activity of the cir- 
culation in the pelvis, prevents the accumulation of fluid in 
that portion of the peritoneum least able, from the injury, to 
take care of it, favors holding away the intestines from the 
injured surface, avoids unpleasant and unfortunate adhesions, 
and is capable of affording great comfort to the patient. If 
the patient has lost much blood and is greatly depressed, hypo- 
dermocleisis should be practised or intravenous injections of 
normal salt solution should be given. Hypodermic injections 
of strychnin, fromi 3V to 2"^ of a grain every two or four hours, of 
atropin, y^ of a grain every twelve hours, and of digitalin, from 
I" to i of a grain every eight to twelve hours, will be found of 
service. The patient should be wrapped in warm blankets 
and surrounded by hot-water bottles, accurately corked and 
well wrapped to prevent the possibility of burning. It should 
not be forgotten that the tissues of a patient profoundly shocked 
have greatly reduced resistance, and, hence, burn at a much 
lower temperature than would affect a healthy person. The 
nurse should be directed to frequently observe the position of 
the hot- water bottles about the patient, for fear that in her 
restlessness she may have brought the unprotected skin in 
contact with the devitalizing heat. Again, the heart's action 
and the tone of the blood-vessels can be greatly improved by 
the administration, hypodermically, of a i : 1000 solution of 
adrenalin chlorid, ten to fifteen drops every two to four hours. 
In greatly enfeebled and shocked patients the limbs should 



GENITAL TUMORS. 681 

be bandaged as far as the trunk to remove the blood from the 
less vital structures to the more important organs. Ice sup- 
positories, consisting of pieces of ice some three inches in length, 
an inch or more in diameter, carefully smoothed and intro- 
duced into the bowel every hour, and enemata of strong coffee, 
normal salt solution, or whisky and peptonized milk may be 
given. Anodynes are contraindicated, and should be used 
only when the pain and distress or the nervous phenomena 
of the patient are so great as to render the unpleasant effects 
of morphin less injurious than these symptoms. The great 
thirst following the operation is overcome by rectal enemata. 
Nothing more than small quantities of hot water should be 
given by the mouth until nausea has been overcome. If, how- 
ever, the patient continues to be nauseated for twenty-four 
hours, vomiting and retching small quantities of material, it is 
better to give a good draft of hot water to furnish the patient 
something upon which the stomach can contract. This acts 
as an irrigation to the stomach and decreases the distress. A 
Seidlitz powder serves well to wash out the stomach. Hare 
advises for this form of nausea the administration of acetanilid, 
gr. ij, and caffein citrate, gr. j, every hour until three doses 
have been taken. Benefit has also been found from small 
doses of cocain. I am very partial to tincture of nux vomica, 
gtt. ij every hour. Vomiting will frequently be allayed by giving 
the patient an enema of chloral, gr. xxx, in warm water, f^ij. 
This brings about sleep and allays the nervous irritation. If 
the patient vomits continuously, regurgitating large quantities 
of dark greenish material, associated with more or less tym- 
panites, the use of the stomach-pump is indicated; the stomach 
is washed out with a normal salt solution until the water re- 
turns clear. When the patient has had several days of this 
condition, follow the cleansing of the stomach with a hypodermic 
injection of morphin, gr. J to J. Tympanites should be treated 
actively; if not relieved by irrigation of the stomach, give the 
patient an enema containing one ounce of powdered alum 
dissolved in a quart of warm water. This enema very actively 
promotes peristalsis. Keith advised: 

R . Quinin, gr. vj 

Whisky, f .^ ss 

Water, ad f .^ ij. M. 

S. — To be used as an enema and repeated every hour for three doses. 

It stimulates the nerve centers, produces increased peristalsis, 
and favors the expulsion of gas. When tympanites occurs 
the second day, in a patient who has otherwise been doing 
well, the following enema should be given: 



682 GYNECOLOGY. 

H, Magnesii sulph.. 
Glycerin., 
Aqua, aa 5 j. M, 

and later an enema of soapsuds, containing turpentine 5j, beaten 
up with the yolks of two eggs and strained before being added 
to a quart of soapsuds. These measures failing, the patient 
should be given a hypodermic injection of strychnin every two 
or three hours, and repeat the irrigation of the intestine later. 
The patient should be placed upon her side, preferably the 
right, with the hips or the foot of the bed elevated, and a large 
quantity of a stimulating enema permitted to run into the 
bowel. Again, the enemas suggested may be supplemented 
by the administration of calomel, gr. J, every fifteen minutes, 
until two or three grains have been given, followed by : 

R . Magnesii sulph., ^ j 

Acid, sulph. dilut f 3 j 

Syr. zingiber. , f .^ vj 

Aq. cinnam. , ad f ^ iv. M. 

S. — f^ss every hour. 

Generally, free evacuation of the bowels is sufficient to relieve 
the unpleasant symptoms, and the patient may then be gradu- 
ally fed. When the nausea and vomiting persist for two, three, 
or more days, the abdomen becomes greatly distended, the 
patient weak and depressed, nothing should be given by the 
stomach, not even water. During this period rectal feeding 
should be practised. The stomach should be carefully irrigated 
with normal salt solution through a stomach-tube. She should 
be ordered three ounces of normal salt solution and one ounce 
of bovinine per rectum every four hours. Peristalsis should 
be overcome by hypodermic injections of morphin, beginning 
with gr. -J to J, and repeat in doses of gr. y^-^ every three or four 
hours, until quiet is secured and maintained. In such cases, 
it is important that the sutures should be retained for a longer 
period. The long-continued disturbance interferes with the 
general nutrition and the processes of repair. The removal 
of the sutures early, or at the usual time, endangers the separa- 
tion of the wound, because the processes of repair have been 
interrupted. In such a patient I removed the sutures on the 
eighth day, and the w^ound split open throughout its entire 
length as a result of a slight cough. Ordinarily, the sutures 
can be removed at the end of the eighth day. The patient 
should be confined to bed for fully three weeks, especially when 
a large incision has been made and the tumor was large. After 
the disturbance of the digestive tract has been overcome, the 
feeding should be generous, exercising care, however, to avoid 
indigestible food. 



GENITAL TUMORS. 683 

550. Puerperal Tumors.— Physometra.^An unusual form of 
enlargement of the uterus, giving the appearance of a tumor, 
results from the condition just named, which is an accumulation 
of gas in the interior of the uterine cavity. This affection 
may be produced during the puerperium or without it. After 
the woman is delivered the uterus is large and air will enter it. 
If expulsion is delayed by contraction of the organ, in the course 
of the convalescence the placental fragments or retained por- 
tions of membrane undergo decomposition, and produce a 
putrid gas, which, by larger accumulations in the organ, pro- 
duces the condition known as physometra. It may develop 
in the nonpuerperal uterus, as is well indicated in the following 
patient, as cited by Auvard: A negress, forty-six years of age, 
reached the menopause and presented considerable abdominal 
enlargement. Her periods had not been seen for three months. 
According to her calculation, she was certainly pregnant. The 
term had passed four months ; she called a physician and ar- 
ranged that he should attend her in labor. Under an attentive 
examination of the patient to determine the cause of the uterine 
enlargement the hysterotome was introduced into the cavity 
of the uterus, when, in less than a minute's -time, with great 
impetuosity, an offensive gas was driven out. After this evac- 
uation the uterus returned to its normal proportions and the 
patient recovered. In the acceptance of this condition we 
must admit the possibility of the secretion of gas in the uterine 
cavity, or the putrefaction of retained intra-uterine debris, 
after the occlusion of the cervical canal. Decomposition of 
the debris results in the formation of gas and the distention of 
the organ. The treatment consists in the establishment of 
the permeability of the canal. 

551. Hydrometra is due to any cause by which the internal 
orifice of the uterus becomes closed and the secretion retained 
in a woman who suffers from amenorrhea or in one suft'ering 
from endometritis after the climacteric has occurred. It prac- 
tically produces a mucometra, or. when the liquid is serous and 
clear, it is denominated hydrometra — a term under which is 
included all seromucous uterine collections. If the endometritis 
is purulent, we have a pyometra. Hydrometra is exceedingly 
rare. 

552. Hematometra is an accumulation of blood in the in- 
terior of the uterus, and has been described under malforma- 
tions. A Avoman sixty years of age came under my observation 
with a history of having a very profuse offensive discharge. 
The discharge was so oft'ensive that it was believed the condition 
must be malignant. The uterus, not very large, was removed, 
and upon careful examination it did not present the slightest 



684 



GYNECOLOGY. 



indication of the presence of malignant disease. The woman 
had been suffering from an endometritis, which had resulted 
in the production of large quantities of purulent fluid in the 
uterine cavity. 

553. Hydatid Cysts of the Uterus. — The condition called 
hydatid cysts of the uterus is, however, free from the presence 
of hydatids. There are a large number of cysts, which form 
in the mucous membrane of the uterine cavity — a condition 

which generally follows 
labor or abortion, and is 
known as cystic mole. 
It is so closely associ- 
ated with the condition 
known as deciduoma 
malignum that its con- 
sideration will be post- 
poned until the discus- 
sion of the latter disease. 
554. Mucous Polypi 
of the Uterus. — These 
are growths which arise 
from the uterine mucous 
membrane, and are dis- 
tinct from the fibroid 
polypi, with which they 
are often confounded. 
(Fig. 481.) The latter 
arise from the muscular 
wall and push before 
them the mucous mem- 
brane. The former re- 
sult from hypertrophy 
of the glandular struc- 
ture of a limited por- 
tion of the uterus, which 
causes them to push out 
and form a polypoid 
growth. A number of 
these may occur within the cavity of the uterus and interfere 
with the performance of its functions. They are associated with 
endometritis. They are due to a localized inflammation and 
hypertrophy of the glandular tissue. These growths may vary 
from the size of a filbert or less to a growth consisting of a 
grape-like cluster of glands attaining the size of a small orange, 
which is extruded from the cervix, and hangs by a pedicle from 
the uterine cavity. These growths may occur upon any part of 




Fig. 481. — Mucous Polypi. 



GENITAL TUMORS. v 685 

the mucous membrane; frequently they arise from the cervix 
and protrude from the os in small masses. The treatment of 
these growths is the same as that of the inflammation ^Yith 
which they are associated: thorough curetment of the uterus; 
removal of the growths; disinfection and sterilization of the 
uterine canal and gauze packing to promote subsequent drain- 
age. The operation should not be devoted to the removal of 
the growths alone, as the cervical canal is likely to become 
irritated and cause subsequent pelvic inflammation. 

Another form of uterine tumor is placental polypus, which 
consists of a mass of coagulated blood, in association with a 
.portion of the placenta or the decidua, which hangs by a pedicle 
from the uterine cavity and acts as a source of irritation until 
its removal. The mass becomes compressed in the uterine 
cavity and forms a flrm growth, which can subsequently be- 
come partly organized, or, under the influence of insufficient 
nutrition, may become decomposed, and cause putrid intoxica- 
tion. The treatment will consist in the thorough removal 
of the growth. This can be done with the finger, or by the 
introduction of forceps, which seize and twist off the tumor. 

555. Malignant Tumors. — By malignant tumors is under- 
stood those which can severely injure or arrest the life function 
of the organism. But this definition is not complete, for the 
reason that it w^ould include a myoma from which the patient 
suffered hemorrhage, or which produces compression of the 
ureters, resulting in hydronephrosis, and fatal uremia. A 
malignant tumor of the uterus, then, is one which destroys 
the organ in which it originates and penetrates to the surround- 
ing structures without limit to its growth. There is no tissue 
of the body which is in a condition to offer resistance to the 
encroachment of so malignant a tumor. Malignant growths 
are further characterized by a tendency to extend themselves 
to remote tissues and organs by passage through the lymph- 
and blood-vessels. Loosened pieces of tissue or infectious 
products are washed aAvay from their original sources to new 
locations, thus affording development to new foci of structure 
similar to that from which they originated. A further char- 
acteristic is that they show a tendency to relapse after removal. 
The limit between malignant and benign tumors is difficult 
to fix. Thus, papillary ovarian cysts may rupture and sub- 
sequently implant themselves upon and infect the general peri- 
toneal cavity. Syphilis and tuberculosis show a disposition 
to extend to the surrounding structures and to be reimplanted 
through the blood-vessels. But the manifestations of syphilis 
and tuberculosis are capable of modification, of arrest, and even 
cure. The papillary infection generally undergoes atrophy 



686 GYNECOLOGY. 

and disappears when the original source of infection has been 
removed. 

556. Classification. — We are equally at a loss to fix a proper 
standard when we come to the classification of these growths. 
The clinical properties are not sufficient for a classification, as 
we find, in growths of dissimilar origin, similar clinical pheno- 
mena. The growths may be divided into carcinoma, sarcoma, 
chorio-epithelioma malignum, and endothelioma. Carcinoma 
originates from the epithelial tissue of the surface and the glan- 
dular structure; sarcoma in the connective tissue; chorio-epithe- 
lioma malignum in the syncytial structure of the ovum, and 
endothelioma from the endothelium of the lymph-vessels, blood- 
vessels, and serous membranes. Carcinomata are distinguished 
from sarcoma by the fact that they develop from the epithelial 
tissue and have rather a distinct tendency to alveolar and 
atypical glandular formation with a fairly well-defined con- 
nective-tissue stroma. The sarcomata, on the other hand, arise 
from the connective-tissue elements and exhibit a more or less 
uniform cellular appearance. Furthermore, they are, as a rule, 
without any alveolar arrangement. 

557. Carcinomata. — Carcinomata are divided, according to 
their anatomical situation, into carcinoma of the neck and of the 
body of the uterus; from their histogenetic structure into the 
squamous-cell carcinoma and cylindric-cell carcinoma or adeno- 
carcinoma. Both these forms occur in the cervix ; the squamous- 
cell in that portion called by the Germans the portio vaginalis, 
which comprises the cervix external to the external os. The 
cylindric-cell carcinoma occurs in the cervical canal between 
the external and internal os. Carcinoma of the body of the 
uterus is almost exclusively of the cylindric-cell variety. How- 
ever, a few rare cases of squamous-cell carcinoma have been 
found in the body of the uterus, and are attributed by Williams 
to the presence of aberrant epithelium. 

558. General Pathology. — (i) Squamous-cell Carcinoma. — 
Squamous-cell carcinoma originates in the pavement epithe- 
lium and affects principally the vaginal portion of the cervix. 
The disease begins as a proliferation of the cells of the deeper 
layer, the rete malpighii, from which down-growths of solid 
processes are sent into the subjacent structures, distending 
their interfibrillar spaces (Fig. 482). The invading processes 
continue to grow and form large alveolar spaces. These as- 
semblages of cells, called cell nests, may be plentiful or scattered. 
In the latter they are often ill formed and difficult to find. Their 
existence, however, should be considered as confirmation of 
the presence of malignant disease. These cones or projections 
find the muscular tissue no bar to their progress. They present 



GENITAL TUMORS. 687 

collections of polymorphous cells which overlie one another 
or are arranged cylindrically, and hence are known as epithe- 
lial pearls. Spaces form in the center of the cone, as a result 
of fatty degeneration or colloid softening, which resemble the 
lumina of gland tubes. The thickening of the epithelium affects 
the deeper layers first, but subsequently the superficial layers 
become involved, thinned, and small papillary projections 
are found hanging from the free surfaces. The continued 
proliferation of the squamous epithelium sooner or later inter- 
feres with the nutrition of the part and results in necrosis and 
subsequent ulceration. The condition can often justly be 








Fig. 482. — Squamous-cell Epithelioma of the Uterus. 
a. Keratinization of cells forming epithelial pearls, b. Connective-tissue ma- 
trix, c. Collection of atypical cells. 

described as a carcinomatous ulcer. This form of carcinoma, 
as we have already seen, is also in rare cases found upon the 
surface lining of the uterine cavity. When in this location, 
it is ascribed to irritation of aberrant cells. 

(2) The cylindric-cell carcinoma of the uterus may be situated 
in either the body or the cervix, and it arises from the cylindric 
epithelium only. The neoplasm originates in the epithelium 
of the cervical or uterine cavity, either in that upon the surface 
or in that lining the glands, but with much greater frequency 
in the latter. Hence, it is called adenocarcinoma of the cervix 
or of the body. The cylindric-cell formation, developing into 



688 



GYNECOLOGY. 



the glandular type, occurs in two incidentally different forms. 
In the one form, the high cylindric epithelium is lower, cubic, 
roundish, or polymorphous, and the nuclei move from their 
original basal site toward the center of the cells and exhibit 
other evidence of change, while the cells at the same time undergo 
proliferation and accumulate toward the lumina of the glands, 
gradually filling up their cavities with cells rich in chromatin. 
As the neoformative process continues, with proliferation into 
the gland lumina, sooner or later centrifugal proliferation takes 
place, and the gland wall or limiting membrane is broken through, 
following which the uterine wall is penetrated in all directions 




Fig. 483. — Adenocarcinoma of Body of the Uterus. 
a. Cells fracturing basement membrane and infiltrating fibrous stroma, b, b, b. 
Intraglandular proliferation of cells, c, c. Irregularity of cells, d, d. 
Epithelial cells infiltrating stroma. 



(Fig. 483). In the second form, which is more rare, the gland 
lumina are filled out by solid cones. This form is difficult to 
differentiate from the squamous-cell cancer. Individual changes 
consist in the loss of the cilia and a change in the situation, 
size, and staining properties of the nucleus. In the early stage 
the cells in the body and cervix retain their characteristic activity 
and the usual situation of the nucleus, so that one can still 
determine whether the carcinoma has originated in the body 
or the cervix. The rupture of the membrana propria and the 
projection of the epithelial processes through the membrane 



GENITAL TUMORS. 689 

wall in all directions cause the disappearance of the normal 
form of the gland and the establishment of epithelial layers. 
The stroma in such cases can be entirely absent, while in others 
it is retained in large processes. This form of cancer occurs 
frequently in the uterine body, quite rarely in the cervix, and 
very rarely in the vaginal portion. In advanced stages the 
gland lumina are partially or completely filled with the epithe- 
lium under simultaneous alterations of form, which process 
develops a pure glandular cancer. This form of disease was 
originally denominated by Ruge adenoma malignum, and he 
endeavored to differentiate it from pure glandular cancer. 
This differentiation, however, can not be accepted, for, in the 
first place, it must be remembered that an adenoma is a benign 
new formation, while the condition under consideration is 
correctly denominated pure cancer, because it destroys locally 
and generally. A malignant adenoma, then, must be classed 
as glandular cancer. It will be recognized that carcinoma 
has no specific cell, but that the cells found in this disease re- 
tain their form and present some characteristics of the par- 
ticular structure from which the disease has originated. These 
cells, of course, undergo modifications of form due to the manner 
in which they are crowded together, but even in their poly- 
morphous forms, when separated, resemble the cells from which 
they have developed. In the cervix these cells are sometimes 
so mixed as to render it difficult to determine the particular 
form of structure from which the malignant process originated, 
especially in cases of laceration of the cervix, where the disease 
involves both the squamous and cylindric epithelium. 

559. Structure of the Stroma. — The stroma of carcinoma 
uteri is acquired from the structure of the portion in which 
the disease has developed. It consists of connective -tissue 
fibers, which have been condensed by the pushing in of the 
epithelial cones. The stroma develops with the proliferation 
of the cells. If the disease progresses outward toward the 
surface of the portio vaginalis, the stroma is also projected out- 
ward and forms the structure or framework for the alveolar 
carcinoma. In infiltration with cancer, the stroma is formed 
from the basic substance of the organ; thus, in cancer of the 
vaginal portion and in that of the cervix the stroma consists of 
connective tissue and muscular structure, while in carcinoma 
of the body it arises from the pure muscular structure. The 
quantity of stroma greatly differs. In the forms of squamous- 
cell carcinoma, as in the pure glandular variety, we have great 
stroma beams, Avhile in many carcinomata of the cervix this 
structure is so thin that the alveoli almost touch. This is 
particularly marked in the carcinomata adenomatosum, in 

44 



690 GYNECOLOGY. 

which the epitheHal structure of their basic surface lies thickly 
together. Investigations disclose that the cells are not attached 
to the stroma. They have penetrated into the stroma as foreign 
bodies, and are not attached to or derived from it. In the 
stroma are situated blood-vessels, lymphatics, and nerves. 
The thinner the stroma, the denser the tumor. Secondary 
alterations in the structure, such as fatty and hyaline degenera- 
tions, are not infrequent. In the squamous-cell variety the 
cervical glands are secondarily involved and the disease enters 
the gland from without. Experience demonstrates that the 
blood-vessels are slow in being involved in carcinoma. Metas- 
tasis through them is very rare. 

Seelig has directed attention to the fact that the capillaries 
remain for a long time intact between the existent carcino- 
matous projections. He once saw the carcinoma collected in 
a ring around a vein, and it had invaded its wall up to the intima. 
Goldman, on the other hand, observed penetration of the car- 
cinoma through the thin walls of a vein, and alterations of the 
endothelium, while the circulation was disturbed by throm- 
bosis formation. Abel also directs attention to the history 
of a patient, thirty-seven years old, who had suffered for two 
months from irregular bleeding and discharge. Examination 
failed to reveal any indication of involvement of the vaginal 
wall or parametrium. Total extirpation of the uterus through 
the vagina was performed, removing as much as possible of 
the broad ligament. On subsequent microscopic investigation 
it was found that some distance from the carcinoma, in a per- 
fectly healthy looking area, a mass of carcinomatous tissue 
had made its way into a vein. The occurrence of such con- 
ditions emphasizes the possibility of carcinomatous masses 
being transmitted through the blood-stream. The principal 
method of extension of carcinoma from the seat of primary 
infection is through the lymph- vessels. The epithelial cones 
spread out into the connective-tissue folds until they gradually 
reach large lymph-spaces. When the disease reaches one of 
these lymph-spaces, it rapidly extends itself. The more rapid 
development of cancer in pregnancy is undoubtedly due to the 
size and width of the lymph-spaces, and in childhood to the 
increased energy of the lymphatic circulation. In senile women, 
the vessels are small, the lymphatic vessel activity greatly de- 
creased, and the extension of the disease is, therefore, very 
slow. When the deeper structures have undergone cellular 
infiltration, the lymph-spaces are opened and rapidly filled. 
Seelig, in his careful investigations upon the progress of the 
disease, noticed the projection forward of carcinomatous masses 
into the endothelial lining of the lymph- vessels. These masses 



GENITAL TUMORS. 691 

more or less obstructed the large vessels, although the vessels 
themselves could still be recognized in the structure. The 
largest lymph-spaces filled with carcinoma were found in the 
margin between the middle and peripheral muscle layer of the 
corpus uteri, where the entire muscular branches anastomose 
vertically. The investigation demonstrated that the carcino- 
matous masses press against the connective tissue or muscle 
fibers until they are enabled to invade the lymph-spaces. The 
obstruction of these vessels not infrequently results in regur- 
gitation currents, by which portions are carried into lymphatic 
spaces in an opposite direction to that of the normal current. 
This probably affords an explanation of the invasion of the 
anterior wall of the vagina from cancerous disease of the cavity. 
With its entrance into the lymph- vessels, the disease is carried 
by the larger paths into the parametrium, where the lymphatics 
are not infrequently found filled with carcinomatous masses. 
They may be carried as emboli from the lymph-spaces into the 
next lymphatic glands without the vessels themselves being 
involved. While it is generally recognized that the principal 
channel of invasion is by w^ay of the lymphatic vessels, yet 
it seems apparent that in malignant disease of the uterus the 
lymph-glands are involved at a later date than in cancer of 
other portions of the body. 

I am aware that this assertion is denied by Ries, Pry or, 
Jacobs and others. The very careful investigations of Ries 
would seem to confirm his assertion that the lymphatic glands 
are involved early in the disease, but it is hard to reconcile this 
with the experience of many operators who have demonstrated 
the failure of malignant disease to recur after vaginal opera- 
tions involving either a partial or complete removal of the uterus. 
Cullen accounts for the failure to involve the lymphatic glands 
as early in carcinoma uteri as in mammary carcinoma, by the 
fact that in the uterine disease there is a greater disproportion 
between the size of the epithelial cells and the lymphatic vessels, 
that the epithelial cells rapidly attain a size too large to permit 
of their passage through the lymphatic vessels, and it is only 
after the disease has reached the large lymphatic spaces and 
vessels that lymphatic gland infection occurs. The investiga- 
tions of Blau and Dybowsky particularly emphasize the infre- 
quent involvement of lymphatic glands in women who have 
died from cancer in the Berlin Charity. The former found 
the lymph-glands of the pelvis involved but thirty times in 
ninety-three sections, while the latter in one hundred and ten 
cases found only ten of lymphatic infection. In cancer of the 
cervix Blau found the lymphatic glands infected in scarcely 
one-third of the cases. The experience of operators would seem 



692 GYNECOLOGY. 

to confirm the claim of the majority of investigators that lymph- 
atic gland involvement occurs much later in uterine cancer than 
in other portions of the body. In the great majority of cases of 
recurrence after operation, the disease is situated at or near the 
site of removal, either in the cicatrix or in the parametrial tissue. 
560. Carcinoma of the Portio Vaginalis. — Carcinoma begins 
as a small nodule in the mucosa, external to the external os. 
This nodule increases in size as a result of proliferation of the 
epithelium and its projection into the fibrous structure. It 
presents itself as a projection upon the surface of the cervix, 
increasing in size and forming dendritic or finger-like masses 




■^ 





Fig. 484. — Cauliflower Growth Involving the Vaginal Part. 

or projections, which consist of vessels with numerous capillaries, 
and stroma filled with epithelial cones. These masses or pro- 
jections may occur from one or both lips of the cervix and form 
a large mass known as cauliflower growth, which may attain 
to considerable size and fill up the vagina (Fig. 484). Another 
form is a small button-shaped mass projecting above the level 
of the cervix, more or less indurated and hardened, the surface 
of which ulcerates, giving rise to an excavated surface with 
hardened, indurated, often overhanging edges. The disease 
spreads from the periphery into the surrounding healthy struc- 
ture and breaks down at its center into a crater-like cavity. 



GENITAL TUMORS. 693 

The tendency of this disease is to spread downward toward the 
vagina rather than upward into the cervical canal. In lacera- 
tion of the cervix or in marked eversion of the cervical mucous 
membrane we may have extension from the squamous epithe- 
lium to the structure which is supplied with cylindric. The 
latter tissue, however, has, as a result of inflammatory con- 
ditions, undergone a previous metaplastic change of its epithe- 
lium, so that it closely resembles that of the squamous. It is 
only when the disease has originated in the racemose glands 
of the part that we find the cylindric epithelium constituting 
the greater part of the disease. Williams was inclined to be- 
lieve that the tissue forming the line of demarcation between 
the pavement and cylindric epithelium at the external os was 
the point most vulnerable to the manifestation of malignant 
disease. Limbeck describes a course of development in which 
there is a continuation of the pure glandular with squamous 
cell-cancer, so that the solid cancer cones of the former variety 
are encompassed and held for a time by the squamous-cell 
form. 

561. Adenocarcinoma of the Cervix. — ^Cancer of the cervix 
comprises the development of the disease in that section of the 
uterine mucous membrane situated between the external and 
internal os. This does not include the cancer which arises 
from erosions and ectropion of the cervical mucous membrane, 
which very soon assumes the clinical form and appearance of 
cancer of the portio. It is a disputed question whether cancer 
of the cervix arises from the cover epithelium of the cervical 
canal. This is positively denied by Williams, while Amann 
attributes it to the atypical proliferation of the cover epithelium 
and regards the glandular alteration as secondary. Winter 
asserts that the disease most frequently arises from the com- 
bined point of origin of glandular and cover epithelium. In 
the glandular variety the cells become anaplastic and polymor- 
phous and fill the alveoli. The gland tubes are mostly thin 
and have small lumina. In other cases they become cystic. 
It is often a question whether the involvement of the glands 
in such cases is a benign or malignant condition. The appear- 
ance of atypical-growing epithelium, of course, is sufficient to 
decide the diagnosis. The determination of the invasion and 
destruction of the gland wall by the proliferating epithelium 
should be considered absolute evidence of the malignant char- 
acter of the diseased process. In cancer involving the gland 
structure, gelatinous degeneration has appeared in the external 
layer of the alveoli, while the centrally situated cells were sur- 
rounded with gelatinous crust. Cases have been observed in 
which there was an abundant mucous colloid separation of 



694 



GYNECOLOGY. 



Fundus. 



the carcinomatous surface. The disease presents itself in a 
number of ways. Thus, it may originate and develop toward 
the cervical cavity; in other cases it develops in the cervical 
tissues and is concealed behind the external os. It may appear 
in the lumen of the cervical canal in the form of tubercles, 
nodules, or papillary growths, which may fill up the cavity 
or be extruded from the os, while the external surface of the 
cervix is scarcely involved. In other cases the extensive in- 
filtration of the diseased mucous membrane immediately within 
the cervix penetrates the entire periphery and produces thicken- 
ing of the whole cervix 
(Fig. 485) or of only the 
infected wall. It may be- 
gin as a circumscribed 
nodule, within the depth 
of the wall, which can 
not be readily recognized. 
Cancer with pure infiltra- 
tion is rare ; most generally 
there is disintegration of 
the new formation either 
upon its surface or in the 
central or deeper part. An 
ulcer begins upon the sur- 
faces, the superficial layers 
of which are thrown off. 
The size of the cervical 
canal is increased, while 
the wall is more or less 
thickened by infiltration. 
This process may be in- 
visible behind an unin- 
volved external os or a 
cavity may exist which is 
accessible, or it may create 
a fissure or more or less 
extensive cavity, the en- 
trance of which is directly through the cervical canal (Fig. 
486). The ulceration may undermine the wall as it extends 
upward, so that portions of the inner wall project free into the 
excavation. Destruction of the carcinomatous structure leads 
to an extensive excavation, which gradually opens through the 
cervical canal in a fissure of considerable breadth. An exten- 
sive portion of the cervical canal may thus be lost. 

The method of extension in adenocarcinoma of the cervix 
is essentially different from carcinoma of the portio vaginalis. 




Fig. 485. — Cancerous Ulceration of Intra 
cervical Canal. 



GENITAL TUMORS. 



695 



In the latter, as has been indicated, the invasion is superficial 
and ulceration early ; but in carcinoma of the cervix the invasion 
is upward and outward through the cervix into the parametrial 
connective tissue, while the portio vaginalis is involved late, 
if at all. Very extensive invasion and degeneration of the 
cervical canal occurs without the os externum presenting any 
break in its continuity or any disturbance of the appearance 
of squamous epithelial covering of the portio vaginalis. We 
need but to remember the changes which the cervix undergoes 
as a result of cystic 

degeneration of its ^ 

glandular structure, 
in which the ducts 
of the cervical glands 
become obstructed, 
the glands distended, 
and in extensive in- 
volvement the walls 
of the cervix to a 
great degree perfor- 
ated, to understand 
that the onset of a 
malignant growth in 
such a field would 
readily penetrate the 
parametrial structures 
before the external os 
presented any indica- 
tion of the grave dis- 
order. Metastasis may 
occur into the walls 
of the vagina, but the 
proper direction of the 
extension is toward 
the body of the uterus 
and into the parame- 
trial tissue. Carci- 
noma not infrequently 

passes through the internal os and invades the mucous mem- 
brane of the uterine body. The disease may invade the entire 
uterine mucosa or only a small portion may be involved. In 
some cases the uterine mucosa may be the seat of isolated cancer 
nests, the result of metastasis. As the disease progresses, the 
thin layer of tissue intervening between the wall and the perito- 
neum is early involved. The vesico-cervical septum, however, is 
much more frequently diseased, and involvement of the bladder, 




Fig. 486. — Cervical Wall Infiltrated while the 
Vaginal Portion is Largely Destroyed. 



696 



GYNECOLOGY. 



also, is not infrequent. The posterior cervical wall and its 
enveloping peritoneum are much- less frequently involved in 
cancer of the cervix, but more frequently than in that of cancer 
of the portio vaginalis. Peritonitis may result from perforation 
or inflammation, and necrosis may cause the development of 
a suppurative peritonitis. When the disease has extended 
forward into the utero vesical septum, the bladder and ureters 
become involved and result in conditions resembling those 
described in carcinoma of the portio vaginalis. 

562. Adenocarcinoma of the Uterine Body. — Carcinoma of 

the body of the uterus arises 
from the cylindric-cell epithe- 
lium of the mucous membrane 
and that lining the glands. It 
may afford considerable diffi- 
culty to determine whether the 
^^ ~ . \ disease has originated from the 

9^ \ \ cover or glandular epithelium. 

This distinction is only made 
from the histogenic standpoint, 
as there is no morphologic dif- 
ference. Cancer arising from 
the cover epithelium can as- 
sume a glandular form, while 
the glandular epithelial cancer 
can completely lose this by fall- 
ing away from the alveoli. It 
is probable that the cover epi- 
thelial cancer never arises from 
the unaltered cylindric epithe- 
lium, but develops only after 
metaplastic alterations have 
taken place. As a result of 
previous inflammation, the cyl- 
inder cells become cubic, strati- 
fied, and exhibit a resemblance 
to the pavement epithelium. 
The neoplasm, as elsewhere, 
consists of epithelioid elements in a connective-tissue basis. In 
its development the boundaries of surrounding tissue are not 
respected, for it grows into the glands and vessels without being 
arrested by their enveloping membranes. The projecting cones 
or nests may preserve a glandular character, and in the center of 
the distended lumina several layers of cubic cells are often no- 
ticed. Not infrequently the cells are arranged in concentric 
layers ; a complete cornification with the characteristic chemical 




Fig. 



487. — Circumscribed Cancer of 
Body of Uterus. 



GENITAL TUMORS. 



697 



reaction is found. Examination of the structure discloses that 
the centrally situated cells are polymorphous and cubic, while 
the peripheral long retain their cylindric type. The extension of 
adenocarcinoma into the deeper structures is evidenced by the 
prolongation of tubular projections down to and between the 
muscle-fibers, pushing and separating them as the disease pro- 
gresses and increases from the periphery. Carcinoma of the 
uterine body manifests itself in different forms. It may appear 
either circumscribed or diffused. In the circumscribed form 
the tumor is frequently found with a roughened, uneven sur- 
face, the shape of which depends upon the size of the uterine 
cavity. At the base of this growth the infiltration extends 
more or less deeply into the uterine structure. Pure infiltrated 
cancer in the circumscribed form is rare. Proliferation from 




Fig. 48 S. — Diffuse Cancer of Uterine Bod^ 



its surface may fill up the uterine cavity and cause it to become 
considerably enlarged (Fig. 487). Occasionally a form of pol- 
ypus is seen with a very small pedicle, from which a consider- 
able sized bell-shaped, spongy nodule arises, which may fill up 
the entire uterine cavity. The appearance of such a growth might 
readily lead one to suppose that he was dealing with a polypoid 
growth of benign character. The removal of the mass, however, 
is rapidly followed by redevelopment, and probably more rapid 
progress from the infection of the injured tissue. Such growths 
may have developed from the infection of one or two glands, 
and proliferation of the epithelial tissue with growth of the 
stroma takes place into the uterine cavity until it is completely 
filled. Such a mass is almost pultaceous, readily breaks down 
under the finger without leaving much outline of its structure 



698 GYNECOLOGY. 

(Fig. 488). In the diffuse variety there is almost simultaneous 
extension of the disease to the entire endometrium. Its papil- 
lary projections, villi, and nodules fill out the entire uterine 
cavity. Carcinomatous infiltration invades the depth of the 
muscular structure and penetrates it more or less deeply. As 
the disease progresses, it either goes toward the free surface 
and fills out the uterine cavity while the depth of infiltration 
is but slight, or it penetrates the entire uterine wall with slight 
growth toward its cavity (Fig. 489). Why the disease should 
manifest these forms is undetermined. 

563. Influence of Carcinoma upon the Surrounding Tissues. — 
The development of malignant infiltration produces a reaction 
in the tissues environing it, which is manifested by extensive 




Fig. 489. — Entire Cavity Covered with Nodular Growths. 

small-cell infiltration and the production of exudation. This 
reaction is regarded as either an actual inflammation produced 
by infection from the surface of the suppurating cancer, or is 
produced in the uterine walls by the pressure of the cancer 
structure. It is actually an inflammation produced in the envel- 
oping tissue by the irritation, and is an effort upon the part 
of nature to establish a barrier against the further progress 
of the malignant disease. The reaction soon envelops the 
alveolar structure of the cancer, frequently covering it over 
so the leukocytes press into the alveoli. In one case of cancer 
of the cervix, Auer observed a distinct thickening of the portio 
epithelium without it partaking of the malignant character. 
The same condition is observed in alterations of the mucous 



GENITAL TUMORS. 699 

membrane in the body of the cervix, which exhibits various 
forms of chronic metritis. In every case of cancer of the uterus 
a certain degree of metritis and endometritis exists. MaHg- 
nant disease is not confined to the uterine walls, but develops 
secondary nests in the parametrium, particularly in the cellular 
tissue between the neck of the uterus and bladder, from which 
there is very early extension to the bladder-wall and ureters. 
When the disease penetrates the uterine wall, if upon the peri- 
toneal surface, extensive adhesions are formed, by which the 
surrounding viscera become glued to the surface of the uterus. 
Such adhesions may involve the bladder, the omentum, or the 
intestine. Through this structure the disease progresses, and 
when finally such a nodule degenerates, an intestinal fistula 
can result. A secondary infection of the peritoneum in Douglas' 
pouch may cause a large tumor sufficient to fill its cavity. Gland- 
ular infection extends to the retroperitoneal lumbar glands 
about the bifurcation of the common iliac from the aorta, al- 
though glandular infection, as we have seen, is a late element 
in the progress of the disease. Metastasis to the abdominal 
viscera is much less likely in cancer of the body than in that 
of the cervix, since the disease does not penetrate the uterine 
wall nearly so rapidly. It is not an unusual occurrence to find 
malignant disease of the uterus complicated by benign ovarian 
tumors, or a cancer of the ovary may be associated. This is 
more common than when the disease originates in the cervix. 
564. Process of Extension. — Carcinoma of the portio vag- 
inalis, of the squamous-cell variety, forms a small nodule or 
elevation, in which cell proliferation usually leads to obstruc- 
tion of the circulation, and, from the deprivation of nutrition, 
necrosis follows, causing an ulcer. The disease penetrates the 
deeper structures, however, much more superficially than in 
adenocarcinoma. It grows also from the margins of the ulcer 
and from new nodules which undergo a similar change. The 
tendency of this form, according to Ruge and Veit, is super- 
ficial; it mostly arises from the upper part of the vagina and 
the mucous membrane which covers the cervix, and show^s 
a tendency to confine the extension to a great degree toward 
the vagina. Winter described a form in which the mucous 
covering of the hypertrophied papillary bodies, next the car- 
cinoma, was apparently raw and excoriated. This layer subse- 
quently underwent infection and carcinomatous degeneration 
followed. The process is somewhat similar to the form described 
bv Schwartz as multiple epithelioma. The mucous membrane 
of the vaginal fornix consisted of soft, spongy, easily broken- 
down growths, which presented a fine papilla-like surface in the 



700 GYNECOLOGY. 

vagina. Microscopic investigation disclosed a pure hyperplasia 
of the vaginal epithelium without carcinomatous degeneration. 
Generally cancer of the portio vaginalis develops as an in- 
filtration in the depth of the structure involved and is covered 
by intact vaginal mucous membrane, which forms an infiltration 
ring of extensive ulcerous destruction involving the entire 
affected part of the vagina. The infiltration extends into the 
supravaginal connective tissue. Occasionally cases of contact 
carcinoma occur, in which the mucous membrane becomes in- 
fected from the carcinoma over which it lies. The rarest form 
is the metastatic disease of the vaginal mucous membrane, in 
which isolated, frequently multiple knots of bluish appearance 
develop in the vagina with special predilection for the pos- 
terior wall of the urethral eminence. Thick nests of infiltration 
beneath the intact mucous membrane may involve the urethra 
and soon become necrotic. The extension of the disease to 
the uterus is no exception. Such an extension is likely to be 
more rapid, however, when the involvement of the cervix is of 
the mixed form, and as a result of cervical eversion, from lacera- 
tion, the glands become infected. Should the disease extend 
toward the vagina, it may involve its anterior wall. A great 
tendency to invade the paravaginal tissue laterally and pos- 
teriorly is manifested. In this connective tissue are found 
nests enclosed in the large lymph-spaces. The uninvolved 
connective tissue could scarcely be called healthy and at the 
same time show inflammatory thickening and swelling into 
which cords project. This phenomenon undoubtedly is an 
expression of the inflammatory reaction to the carcinomatous 
disease. The bladder and ureters are involved only when the 
disease affects the anterior lip, and then only after it has passed 
into the anterior vaginal fornix or has reached the same through 
the vesico-cervical septum. Disease of the bladder occurs 
only in the more advanced cases. The first indication of ex- 
tension to the bladder consists in the folds becoming thickened, 
swollen, and lying parallel to one another with deep intervening 
depressions. The mucous membrane may be elevated by 
small vesicles, associated with which is a deep catarrhal altera- 
tion of the mucous membrane. Carcinomatous nodules from 
the size of a pea to that of a walnut appear in the trigonum 
later. These nodules make their appearance at the internal 
orifice of the urethra and incidentally in the mouths of the 
ureters. Blau describes a case in which the entire mucous 
membrane had undergone an infiltration, from direct implan- 
tation, in the form of nodules and papillary growths. With 
the disintegration of these masses, fistulous ulcers follow, which 
have a cancerous infiltrated border. Such alterations can affect 



GENITAL TUMORS. 



701 



either the bladder or the ureteral openings (Fig. 490). The 
most dangerous invasion occurs when the mass invoh^es the 
ureter and may grow around and compress it. I have frequently 
seen the structures about the ureter involved, causing stenosis 
and dilatation of the portion above, until the ureter became 
larger than the finger and the cavity of the kidney sacculated. 
In adenocarcinoma of the cervix the disease very rapidly 
involves the entire glandular structure, especially w^hen it has 
been previously diseased. The glands have already penetrated 
the cervical wall, and it can be readily appreciated why the 




Fig. 490. — Communication between Bladder, Vagina, and Rectum. 



disease has already reached the parametrial tissue when it is 
first discovered. The invasion of the parametrial tissue leads 
to more or less thickening and rigidity of the pelvic floor, the 
uterus becoming more fixed. The disease can progress down- 
ward toward the cervix ; metastasis takes place into the anterior 
wall of the vagina, probably for the reason that it follows a chain 
of lymphatics. It may be that blocking of the lymphatics 
gives rise to regurgitant currents, Avhich carry backward nests 
of the disease to develop in the vaginal wall. Carcinoma of the 
body of the uterus is much slower in making its progress into 



702 GYNECOLOGY. 

the uterine wall, and we frequently see the entire uterine mucosa 
involved without much extension into the muscular structure. 
In other cases the disease is seen making its way through the 
muscular structure and presenting itself beneath the perito- 
neum in the form of nests or nodules. These frequently cause 
inflammatory reaction and adhesions. In the cervical variety 
a nodule may be found projecting into the wall of the ureter. 
This, of course, interferes with the outward flow of urine ; indeed, 
as the disease progresses, the canal lumen will be totally de- 
stroyed and complete obstruction result. It has already been 
mentioned that involvement of the lymphatic glands occurs 
late in malignant disease of the uterus. The lymphatic glands 
which are most likely to become involved in cancer of the portio 
vaginalis are the collection of two or three lymph-glands which 
are situated before the sacro-iliac articulation beneath the 
entrance of the pelvic plane, usually at the division of the com- 
mon into the external and internal iliac arteries. From these 
glands, through the lymphatic anastomosis, the disease may 
be carried to glands in other portions of the body. Petit ob- 
served a pigeon-egg-sized diseased gland in the region of the 
supraclavicular gland in an inoperable cancer of the cervix. 
Dybowsky found inflammation in the mesenteric, bronchial, 
renal, the enteric, mediastinal, jugular, cervical, and supra- 
clavicular glands when the disease had originated in the uterus. 
It remained undetermined whether the infection in these cases 
had been carried through the lymph or the blood-vessels. It 
remains evident, however, that lymph infection in uterine 
cancer does not recur so early or to so extensive a degree in 
carcinoma of the uterus as in that of the mammary gland. 
CuUen attributes this to the fact that there is a greater dispro- 
portion between the size of the involved epithelium and the 
lymphatic vessels, and it is only when the disease has invaded 
the structures to such a degree that large vessels are reached 
and invaded, that such infection takes place. 

565. Clinical Forms. — We have already seen that cancer 
is divided from a histogenic standpoint into two forms, the squa- 
mous-cell and the cylindric-cell cancer; clinically it is divided 
into carcinoma of the portio vaginalis of the cervix and of the 
body of the uterus. It is still further divided clinically accord- 
ing to the course that the disease pursues and the physical signs 
presented. Thus, a malignant formation of epithelial masses 
may break down upon its surface or in its center. The growth 
can project from the portio vaginalis into the lumen of the 
vagina, or, at the same time, the connective tissue of the portio 
be occupied by the stroma and penetrated to its depth by cancer 
masses. This most frequently develops itself in the cancer 



GENITAL TUMORS. 



703 



of the portio above the level and toward the lumen of the vagina, 
by which is secreted a superficially situated tumor which is 
known as a cauliflower growth. It lies as a more or less roundish 
polypoid tumor in the vagina, which may completely distend 
it and present a tumor the size of a fist, which becomes more 
contracted and firmer as we approach the healthy structure. 
The surface of the cauliflower, after desquamation of its pave- 
ment epithelium, reveals exposed carcinomatous masses and 
creates an irregular or papillary condition. When the disease 
has had a longer duration, with unfavorable nutrition of its 
interior surface and with compression of the vessels, masses 
become necrotic and the cauliflower 
growth is covered with a grayish, 
greenish, smeary mass. Such growths 
most frequently take their origin from 
the posterior lip. In many cases the 
disease arises in one commissure and 
extends from it to the lip, rarely the 
entire portio vaginalis is simultane- 
ously degenerated. In other cases pro- 
cesses of epithelial growth project into 
the substance of the portio, and in 
deep infiltration there is thickening of 
one lip of the commissure. In rare 
cases the entire portio vaginalis be- 
comes involved and the more affected 
lip grows toward the lumen of the 
vagina. This form differs from the 
cauliflower growth by being polypoid 
and by having a mucous membrane 
drawn over it, which is rarely quite 
intact. Frequently the mucous mem- 
brane is thrown off in superficial layers 
and is followed by disintegration of the 
surface of the infiltration, or it begins 

in the center and opens through the infiltration to the outside. A 
smooth funnel or fissure will thus be formed, with jagged, often 
undermined borders, sharply lying toward the circumference and 
appearing under the level of the healthy surroundings. In such 
a fissure an ulcer will occasionally dissect deeply into the portio. 
Movable polypoid tumors will project into the ulcer or around 
the cervical canal, without special alteration of the canal itself 
(Fig. 491). Smooth ulcers are occasionally observed, similar to 
the erosion which extends to a very trifiing depth. Why these 
variations in the progress of the disease exist is as yet undeter- 
mined. 




Fi< 



491. — Cervical Canal 
Destroyed by Progress 
of Disease. 



704 GYNECOLOGY. 

566. Etiology. — Of the causes of malignant disease we have 
as yet no definite knowledge, and are forced to accept that theory 
which affords the most plausible view of its development. Among 
some of the more important theories as to its development are 
Virchow's, that while cancer is of epithelial origin, it is only 
through metaplasia or mesodermal elements that it originates ; in 
other words, a transformation of the connective -tissue cells. 
Cohnheim advocates the theory that it was transmitted from 
embryonic carcinoma germs. Riberts believed the epithelial cells 
separated from their connection without anaplasia ; Thiersch and 
Waldeyer, that by primary growth of the epithelium, without 
alterations of biologic properties of the epithelial cells. All agree 
that there is no distinctive cancer cell. 

In recent years increased attention has been concentrated 
upon the determination of some micro-organism which shall 
prove to be a causative factor. Such a theory seems favored 
by the natural history of the disease, its mode of origin, its 
invasion of the surrounding structure, and its transmission by 
the blood- and lymph- vessels. The mere fact that a specific 
micro-organism has never been isolated and recognized is not a 
convincing objection, for syphilis has bafiied all attempts to 
recognize its essential organism, yet no one doubts that it is so 
transmitted. Klebs presented a bacillus, but later investigations 
have failed to confirm its existence. The presence of cancer 
results in the development of micro-organisms of various kinds, 
just as we find in other inflammatory processes, but none of 
those recognized will reproduce the disease. Various degenera- 
tive processes in the cells have been indicated as possessing the 
parasitic elements, only to be proved untenable. Schwarz has 
most convincingly demonstrated that the majority of cell altera- 
tions favoring the parasitic theory have so far resulted from 
degenerative processes of the epithelial cells, leukocytes or their 
derivatives. A fundamental pathologic difference exists in that 
with the malignant a further extension of the processes in the 
organism is influenced by the cell activity, and there is as yet 
absolutely wanting any proof of isolation of a parasite from 
which the disease can be generated by its employment. The 
absence of any history of the transmission from man to animal 
or from one animal to another has been cited. 

The occurrence of carcinoma in the penis of the male who 
has cohabited with a cancerous female is so rare as to be the 
exception to the rule, yet these negative arguments are only 
additional evidence that we do not know the micro-organism or 
its natural history. Surgeons not infrequently injure themselves 
while operating, but no authentic case exists by which the 
development of cancer can thus be traced. Evidently, increasing 



GENITAL TUMORS. 705 

age forms in the cell a disposition to carcinomatous degeneration. 
Statistics indicate that a uterine cancer before the twentieth year 
does not occur, and that it is only rarely observed during the 
next ten years. It is present with increased frequency during 
the third decennium, but the majority of cases are found in the 
fourth. Thiersch believed the greater frequency of cancer with 
advancing age w^as due to atrophy of the connective tissue, which 
favored the deeper infiltration of the epithelial tissue, but this is 
a mere hypothesis. Undoubtedly carcinoma occurs with much 
greater frequency now than formerly. Reyburn and Lewers 
attribute this to diet, and direct the attention to the infrequency 
of this disease among rice-eating populations. They assert that 
the disease is largely due to the consumption of large quantities 
of meat. 

Heredity. — Inherited predisposition to the development of 
cancer has been regarded as an important factor, but careful re- 
searches by Gusserow showed but 7.4 per cent, favoring such a 
tendency, while von Winckel found but 6.3 per cent. Inherited 
lowered resistance to disease, as shown in families predisposed to 
tuberculosis and chronic renal disease, favors the development of 
malignancy. 

Sex. — Twice as many women suffer from cancer as men. Next 
to the mammary gland, the disease occurs more frequently in the 
uterus. According to Hofmeier, fully one-fourth of all cancers 
are uterine. 

Condition of Life. — Cancer of the uterus greatly preponderates 
in the poorer classes, in whom the feeble nutrition, great toil, and 
more exacting lives favor degenerative processes. 

Sextial Activity. — All statistics prove that malignant disease 
preponderates in those who lead an active sexual life, especially 
in the muciparous woman. Gusserow' s investigation of a large 
number of cases gave the average of fruitful labors in cancerously 
afflicted women as 5.1 per cent. — a proportion of births consider- 
ably above the average for women taken together. Accepting 
the irritation theory of Virchow as a factor, we can readily appre- 
ciate the greater frequency of cancer of the cervix. The possi- 
bility of cancer of the cervix in the chaste virgin has been doubted, 
but I have seen several single women of unquestionable virtue 
who suffered from cancer of the cervix. Cancer of the body of 
the uterus is comparatively more frequent in the unmarried and 
nulliparous women. The theory that cancer can be produced by 
excessive coition is not borne out in the lives of prostitutes. Car- 
cinoma may be secondary in the uterus, having originated in the 
bladder or vagina. Myoma of the uterus is sometimes associated 
with cancer, but not so frequently as to render it noticeable as a 
predisposing cause. Landau is inclined to assign syphilis as a 

45 



706 GYNECOLOGY. 

predisposing cause, but my observation does not incline me to 
accept it. Von Winckel's assertion that gonorrhea is an im- 
portant factor in the development of cancer needs confirmation. 
With all our investigations we are driven back to irritation as 
a cause for malignant disease, but its existence does not always 
determine such a degeneration. We are forced to acknowledge 
that we do not know why cancer develops. 

567. Symptoms. — Unfortunately, in the early stages no symp- 
toms, either subjective or objective, are sufficiently marked to 
give warning of the impending danger. As a consequence, the 
physician rarely has an opportunity to investigate the disease 
early. Cancer has no pathognomonic signs ; the principal symp- 
toms — hemorrhage, more or less offensive discharge, and pain — 
are not constant in all cases, and each one may be produced by 
other than malignant conditions. Bleeding is the S3^mptom of 
greatest significance, and may occur when the canal of the 
cervix is affected, though the vaginal margin is uninvolved. The 
quantity of blood lost will probably be slight and irregular, as 
a few drops after severe exertion, straining at stool, or following 
the act of coition. In the married post-coitive hemorrhage is a 
most constant and suggestive symptom. Generally the first 
intimation will be an increase of the amount of blood lost at 
menstruation, or the flow will be continued unduly long, but this 
is not constant. In other cases the first indication will be a 
profuse bleeding. After the occurrence of the climacteric, an 
occasionally more or less profuse bleeding will occur at intervals, 
which causes the patient to think that her menses have returned. 
Post-climacteric pudendal bleeding should always be regarded as 
a serious danger-signal until careful and painstaking examination 
has demonstrated the contrary. As the disease advances, hemor- 
rhage becomes more active, the blood is discharged in a continu- 
ous bright stream, or more frequently in large clots, which are 
formed in the vagina. Frequently the hemorrhage is accompa- 
nied by a discharge of fragments of disintegrating tissue. The 
continuation of hemorrhage produces marked anemia and pro- 
motes the cachexia, but is rarely the direct cause of death. 
Unfortunately, women generally regard increased and irregular 
bleeding as a necessary concomitant to the climacteric, a view 
which is maintained too frequently by the attending physician. 
On the contrary, any excess and irregularity in the flow should 
always be regarded as an indication of grave danger, demanding 
most thorough investigation of the genital tract, supplemented 
by microscopic investigation, if necessary, to ascertain the 
specific cause. Nothing should be taken for granted or left to 
chance. No palliative measures or remedies to arrest bleeding 
should be employed prior to an examination. If the physician 



GENITAL TUMORS. 707 

is unable to satisfy himself as to the cause, duty to his patient 
demands that she shall have the benefit of further consultation. 

Offensive discharge is next to hemorrhage in the time and 
frequency of its appearance. In an early stage the discharge is 
slimy and serous and does not have an especially penetrating 
and offensive odor. As the disease advances and is associated 
with ulceration and disintegration of tissue, the secretion changes ; 
it becomes yellowish; then, with a mixture of blood, and dis- 
integrating tissue, reddish and brownish; and, finally, a dark, 
smeary mass. At first it has a stale, sweetish odor, becomes more 
disagreeable, and finally presents an intensely penetrating, stink- 
ing smell, alike disgusting to the patient and to her attendants. 
When patients have suffered from cervical discharge possibly for 
years, little attention is given to the increase of the amount 
until the odor becomes so marked and disagreeable as to demand 
consideration, when it will frequently be found that the time for 
successful treatment has probably passed. Decomposition of the 
secretion is undoubtedly due to saprophytic or putrescent germs, 
and the greater accessibility of the cervix causes the odor of 
its secretion to become earlier affected than that of the uterine 
cavity. 

Pain is a comparatively late symptom. The cervix, as is well 
known, is not a specially sensitive structure, and the severe pain 
occurs with the involvement of the parametrium, and is later 
increased by pressure upon nerve-trunks. In uterine cancer, or 
when it involves the cervical canal, pain is more marked, and is 
an earlier symptom, owing to encroachment upon the internal 
OS and obstruction to the canal. The absence of pain leads many 
patients to regard the increased bleeding and discharge with less 
suspicion. When an effort is made to impress a woman so 
afflicted with the gravity of the situation, she will doubtingly 
exclaim: "Why, I have no pain!" Slightly extended nodules 
near the cervix, by pressure upon the nervous plexuses in the 
retroperitoneal connective tissue, may produce a lively, persistent 
boring pain in the depth of the pelvis, which is increased to 
an extraordinary degree by the slightest extension. It causes 
persistent lancinating pain, which is not alleviated by continuous 
rest in bed, and only the persistent employment of narcotics 
affords any mitigation. As the disease approaches the peritoneal 
surface the pain is increased, serious reaction in the nutrition 
is induced, from which inflammatory adhesions with the sur- 
rounding structures are the result, and an extensive peritonitis 
is thus caused. The abdomen is sensitive to pressure, and, 
according to Schroder, vaginal examination reveals the uterus 
surrounded by board-like hardness. Not infrequently the symp- 
toms may be aggravated by compression and narrowing of the 



708 GYNECOLOGY. 

rectum through advancing infiltration of the pelvic connective 
tissue. 

The mechanical obstruction to the passage of fecal masses is 
generally associated with severe, agonizing pain; obstinate con- 
stipation arises, partly from the mechanical hindrance, but much 
more from the desire to avoid the severe pain at stool. . In 
cancer of the neck of the uterus, when the disease is transmitted 
to the bladder-wall, even before the entire wall is penetrated 
there is a burning sensation during the evacuation of urine, soon 
followed by tenesmus, frequent micturition, bloody, clouded, or 
purulent urine, with persistent vesical pain. With the infiltra- 
tion and necrosis of the structure a direct communication follows. 
The admixture of ammoniacal urine with the offensive vaginal 
discharge aggravates the already lamentable condition of the 
patient by a horrible stench. The profuse, irritating vaginal 
discharge produces an extensive erythema of the vulva and 
inner sides of the thighs, and causes the patient to complain of 
the intense itching, or pruritus vulvae. 

The offensive character of the pudendal discharge may be 
still more aggravated when the disease involves the peritoneal 
surfaces of Douglas' pouch and is transmitted to the rectum and 
upper part of the rectovaginal septum, which breaks down and 
forms a rectovaginal opening. Occasionally, a large cloaca is 
formed, into which is discharged urine and feces, mixed with 
decaying tissue, and forming a most deplorable condition. For- 
tunately, the rectum is less frequently involved than the bladder. 
Frommel asserts that vesical fistula appears in one-third of all 
cases, rectal fistula in one-sixth. In the progress of the cancerous 
infiltration on either side or in front of the cervix, the ureters 
will sooner or later become involved. The infiltration extends 
about and compresses their lumina, attacks the structures of the 
wall, and may finally completely occlude it. So long as the 
passage of urine remains free, the patient experiences no ill 
effect, but the compression causes a gradual dilatation of the 
ureter and pelvis of the kidney; a condition of hydronephrosis 
follows, and indications of uremia. If but one side is affected, 
the other kidney does compensatory work, and, beyond a possible 
sense of fullness and weight in the affected organ, there is but 
little discomfort. When both organs are compressed, uremic 
symptoms follow, though never violent, rarely convulsive, and 
gradual coma is developed, which causes increased indifference to 
surroundings, and, fortunately, to the profuse pain. Disgust for 
food is marked. Vomiting frequently occurs and suppression of 
urine may be present. The condition has its compensation in 
that such patients are relieved by the coma from previously 
marked pain. 



GENITAL TUMORS. 709 

Reduction in pressure from degenerative changes in the infil- 
tration will often restore the caliber of the canal and permit the 
urine to pass. The sensorium will become free and so continue 
until new compression symptoms appear. An autopsy frequently 
discloses above the cancer infiltration dilated ureters, sacculated 
kidneys, occasionally pyelonephrosis and amyloid degeneration 
of the kidney. Continuation of the infiltration processes causes 
obstruction of the veins and arteries of the pelvis with edema 
of the vulva and of the lower extremities. Hemorrhoidal veins 
become greatly distended and cause profuse bleeding. The re- 
sistance of the peritoneum to the encroachment of the disease 
is very marked. Its approach to the peritoneum is followed by 
reactive inflammation and extensive adhesions, so that cancerous 
nodules rarely reach the peritoneal cavity. Sepsis is also rare. 
When septic peritonitis is produced, it is caused by rupture, by 
pyosalpinx, or by penetration of the cavity from the cancerous 
nest. While sapremic symptoms are frequently associated with 
cancer, the temperature elevation is not high, for the reason that 
the disintegrating tissue is usually shut off from the general 
system by a zone of hard infiltration tissue, which is not very 
absorptive. When high temperature is present, it is generally 
due to an extension of the disease to other organs, especially the 
bladder. It is very important to ascertain the presence of metas- 
tasis to other organs. In the ordinary course of the disease it 
extends to the vagina, bladder, rectum, and vulva; but it may 
reach the same glands by metastasis, as well as the ovary and 
retroperitoneal glands. Metastasis may occur into remote or- 
gans, as, the liver, lungs, and kidney, although the number of 
cases in which wide diffusion occurs is comparatively few. 

Cancer affects the mature, debilitated, and overworked, but 
is also found in the well nourished, and not infrequently in the 
comparatively young. (Fig. 492.) The disease in the latter is 
usually much more rapid in its cotirse. Its mere existence is an 
evidence of lessened resistance to its ravages. In the early 
stages, with patients in good condition, the general appearance 
would contraindicate its existence; but with recurring hemor- 
rhage and discharge, emaciation rapidly occurs. Emaciation is 
more rapid when to the other symptoms is added pain, which 
robs the patient of her night's rest. To the drain from hemor- 
rhage and to the loss of rest is soon added the depressing effect 
of the putrid changes, from a collection of organisms which exert 
a very painful influence upon the general condition. The skin is 
pale, and gradually becomes a smutty yellow from increased 
emaciation. The eyes are sunken and the skin is thrown into 
loose folds or appears to be drawn over the skeleton. A patient 
exhibiting such changes is said to be cachectic. The indications 



710 GYNECOLOGY. 

of suffering are stamped upon the countenance so indelibly as 
to be readily recognized by the experienced observer. From 
other conditions causing uterine hemorrhage, as myoma espe- 
cially, a cancerous patient is recognized by the tanned appearance 
of the skin and the progressive emaciation. In myoma she may 
become pale, anemic, and often yellow, but there is no loss of 
flesh. Indeed, the embonpoint seems increased. In cancer the 
loss of strength is aggravated through the increased disgust for 
food occasioned by the foul-smelling atmosphere in which she is 
forced to live. Gusserow's view is undoubtedly correct, that the 
intense odor occasions the nausea and is made manifest by the 
return of appetite, when by any medical or surgical procedure 
this symptom is temporarily removed. Vomiting is generally a 




Fig. 492. — Uterus Removed from an Unmarried Woman Twenty-two Years 

of Age. 

late symptom and most frequently the result of uremia. Rarely, 
it may be occasioned by invasion of the peritoneum. The loss 
of strength and flesh is progressive, until finally the patient dies 
in profound marasmus. Occasionally, she suffers no convulsive 
attacks from uremia, but just sufficient coma to render her 
insensible to the discomfort of the condition. In some cases 
septic or carcinomatous peritonitis, pleurisy, pneumonia, lung 
embolism, or amyloid degeneration of the large glands leads to 
a premature end. 

568. Physical Signs. — In the previous discussion it has been 
asserted that carcinoma has no pathognomonic symptoms, conse- 
quently its early recognition will largely depend upon the correct 
interpretation of the physical signs. Unfortunately, the patient 



GENITAL TUMORS. 711 

may have no symptoms affording such discomfort that she will 
feel it necessary to consult a physician, and as a natural conse- 
quence the disease will often be advanced before the patient 
comes under observation. Many patients do come under ob- 
servation, however, and are subjected to local treatment for 
other conditions than the grave one which should attract the 
attention of the observer, and valuable time is thus lost. It is 
to save these cases that, at the risk of reiteration, this section 
is written. The disease in many cases is hidden within the 
uterus and the physical signs consequently obscured. Fortu- 
nately, in the great majority of patients the disease affects the 
cervix and cervical canal. The squamous-cell cancer affects the 
external portion of the cervix and appears as a small tubercle 
or projection upon one or the other lip of the cervix. In the 
majority of cases a more or less extensive laceration of the 
cervix will be present. This tubercle will give the sensation to 
the examining finger of a shot-like mass, but manipulation of 
it is associated with slight bleeding and often the papule will 
be friable and can be broken off. As the disease advances, the 
surface presents a superficial ulceration, which is above the level 
of the surrounding healthy structure. Its edges are prominent, 
infiltrated, ragged, often overhanging; its surface more or less 
excavated, covered with friable tissue, portions of which are 
easily broken off, and it has an infiltrated base. Pressure against 
such a surface with a sound permits the point of the instrument 
to become buried in friable tissue. The most careful examination 
is attended with bleeding. Frequently the vagina will be found 
occupied by a mass which may vary from the size of a filbert 
to that of a good-sized fist. Such a tumor presents an irregular, 
pinkish-gray surface, often covered with a greenish-yellow exu- 
date. The mass is continuous with one lip or the entire cervix 
may be involved. The surface has a granular, friable feel, will 
readily give way under the pressure of the finger or of an instru- 
ment, and is associated with a very offensive discharge. Adeno- 
carcinoma within the cervical canal may make extensive progress 
before it becomes visible. Even when invisible, the external 
portion of the cervix appears paler, gives a sensation of hardness 
or resistance to the examining finger, which is firmer and less 
elastic than when due to inflammatory exudation. The cervix 
will often feel hard and dense when carefully palpated, and the 
pressure usually causes a discharge of blood from the os. Very 
frequently the existence of a laceration will permit access of the 
finger, which will reveal the presence of hard nodules, fragments 
of which are easily broken away. The surfaces instead may 
present a large mass of infiltration, the center of which has 
become necrosed, affording an excavation with infiltrated, over- 



712 GYNECOLOGY. 

hanging edges and a pultaceous, friable surface. In more ad- 
vanced cases the cervix may be a mere shell, a large part of 
the uterus being involved. The infiltration can be recognized 
to involve the walls of the vagina, the lumen of which is con- 
tracted by the disease. Carcinoma of the uterine body may be 
inaccessible to touch until well advanced, unless its uterine canal 
is subject to dilatation. Intrauterine indagation reveals an 
outgrowth from a portion or the whole of the uterine cavity, 
which, soft and friable to the finger, rests upon a firm and 
indurated base. When the wall of the uterus is extensively in- 
filtrated, the increased resistance can be recognized by recto - 
abdominal palpation. The penetration of the uterine wall by 
the infiltrate is recognized in the nodules beneath the peritoneum, 
which roughen the otherwise smooth surface of the uterus. No 
discussion of the physical signs of carcinoma is complete without 
a consideration of the revelations of the microscope, but as they 
have been partially studied under the various forms of disease, 
and will be further under diagnosis, I will not discuss them here. 

569. Complications. — The more frequent complications of 
uterine cancer are myoma, ovarian tumor, peri-uterine inflamma- 
tion, and pregnancy. Myoma usually does, and ovarian tumor 
may, precede the development of carcinoma. Attention has been 
recently directed to the association of myoma and carcinoma 
in the same patient (see Fig. 460), with some effort to indicate 
the causative relation; but with the great frequency of uterine 
myoma it would not be surprising should we find, even more 
frequently than is now recognized, the coexistence of car- 
cinoma. The disease begins in the uterine mucous membrane, 
and may subsequently extend and infiltrate the growth. The 
growth can be primarily affected only when there is included in 
it some glandular structure. It has occurred to me that the 
irritation induced by the prolonged use of electricity for its 
influence upon the fibroid growth may favor the development of 
malignant disease. I have seen carcinoma occur in two cases 
subsequent to the application of electricity, but the cases under 
observation have been so few that to make this assertion would 
be no more correct than to assign myoma as the cause of the 
cancer. Ovarian tumor may be benign or malignant. Benign 
growths may become secondarily involved. The cancerous tumor 
of the ovary, however, varies greatly in its influence and in its 
manner of progress from the benign. 

Peri-uterine Inflammation. — Peri-uterine inflammation may 
precede or be the consequence of the malignant disease. In the 
latter instance it is simply a reactive inflammation in which 
nature endeavors to bar the progress of the malignant disorder. 
It is important, in investigation of the case, however, to differen- 



GENITAL TUMORS. 713 

tiate between the peri-uterine exudation and the cancerous 
infiltration, as such a diagnosis would influence the operator in 
his treatment of the cancerous uterus. 

Pregnancy is a not infrequent complication of malignant dis- 
ease. Carcinoma in its earliest stages does not contraindicate the 
occurrence of pregnancy. The association of uterine cancer with 
pregnancy and labor presents the gravest danger for two human 
beings. The frequency of the complication may be determined 
by the consideration of the following statistics : Von Winckel in 
20,000 labors reported lo, and Stratz 7 in less than 18,000; in 
the Tubingen clinic, in fifteen years, out of 5001 labors there 
were 7 complicated with carcinoma. One cause of the few cases 
of association of pregnancy and carcinoma is the fact that the 
latter exists in the great majority of cases in the later years of 
life after the period of fertility is more or less nearly passed. 
The situation of the disease will have something to do with the 
possibility of pregnancy. In 89 cases of associated pregnancy 
and carcinoma the malignant disease was found 38 times in the 
cervical canal and 47 times in the portio vaginalis. In four 
cases the site was not determined. 

The disease, when complicated by pregnancy, presents no 
symptoms essentially different from those in the uncomplicated 
cases, but with the necessarily increased congestion of the pelvic 
organs makes more rapid progress, so the characteristic symp- 
toms — hemorrhage, discharge, and pain — rapidly become aggra- 
vated. Hemorrhage is increased, is more or less copious, and 
is associated with an offensive odor. A profuse, watery, exceed- 
ingly offensive discharge, at times purulent and brownish, is 
constant. The discharge is more abundant and putrid the more 
marked the tissue destruction in the new formation. 
^ It is of interest to study the effect of carcinoma on pregnancy 
and labor. The disturbances which such complications can 
induce in the course of pregnancy and labor must necessarily 
depend upon the situation and extension of carcinomatous dis- 
ease ; sometimes they are only trifling, but occasionally they may 
mean the death of mother and child. The progressive and severe 
hemorrhage, the profuse leukorrheal discharge, associated with a 
complication of pregnancy, result in general anemia, which pro- 
duces a gradual loss of strength. The existence of the trouble 
renders the development of cancer much more rapid, and conse- 
quently early interference should be considered as indicated. 
The influence upon the labor, when the pregnancy goes to full 
term, depends entirely upon the situation of the disease. The 
accompanying endometritic processes can lead to existence of 
placenta praevia. When the disease is confined to the vaginal 
portion of the cervix, it will not be impossible for labor to be 



714 GYNECOLOGY. 

Spontaneous, but obstructions occur as soon as the portio is circu- 
larly seized in its entire circumference; or, if the cervical canal 
has become strongly infiltrated, the tissue is absolutely unyield- 
ing. Unless prompt measures are resorted to, such an individual 
may suffer from hemorrhage, exhaustion, and fatal termination, 
with the fetus still intra partum. 

Among the complications with labor we can have premature 
rupture of the bladder and weak labor pains. If the pains 
remain active, the embryo is forced through, and the process 
results in extensive tearing of the cervix, which may extend to 
the pericervical connective tissue, cause the most extensive 
bruising and crushing of the birth canal, and the cervix may 
even be torn away above the infiltrated ring. Equally significant 
is the influence of pregnancy and labor upon the cancer. As 
has been mentioned, it was considered that the existence of 
pregnancy had a beneficial influence on the progress of the cancer 
growth. Von Siebold is reported to have observed the spon- 
taneous recovery of genital cancer from a simultaneous preg- 
nancy. The experience of recent years combats this idea. The 
rapidity of the growth depends upon the character of the disease, 
being much more rapid in the soft and medullary form than 
in the scirrhous variety. The labor can cause the most extensive 
destruction of the parts, and, not only this, but be followed by 
infection of the tissue, which can result in thrombosis, sepsis, 
and pyemia. 

570. Diagnosis. — The early recognition of cancer will fre- 
quently afford the only hope for its radical relief. The investi- 
gations of Virchow dismissed the idea of cancer being in origin 
a constitutional disease and demonstrated its purely local charac- 
ter. A study of its clinical course, however, indicates that while 
the disease is local in character at its origin, transmission to 
the surrounding structures takes place, when the disease prac- 
tically becomes constitutional. It is important, therefore, that 
the practitioner should recognize the gravity of the disease at 
the earliest possible moment. When the condition is one of 
doubt, the attending physician, in the interest of his patient, 
should have the doubt resolved by securing the advice of a more 
experienced man. Only by early recognition and by radical 
treatment before the extension of nests into the parametrial tissue 
can we hope to avoid the fatal termination of this disease. It is 
well recognized that many patients fail to appreciate the gravity 
of their symptoms and postpone consulting a physician until the 
favorable period for intervention has passed, but it is equally true 
that many others are subjected to general or local treatment or 
are advised to await the change of life until the disease has 
become hopelessly inoperable. This is frequently brought about 
through aversion of the patient to the gynecologic examination, 



GENITAL TUMORS. 715 

but the physician will be wiser in absolutely declining to accept 
the responsibility for the treatment of a patient who declines 
to permit him to employ the necessary means to determine her 
condition. Should he yield to her request, she and her friends 
will subsequently hold him responsible for any untoward results. 

The ease with which the diagnosis can be made will depend 
upon the situation of the disease. Following the division already 
given of cancer involving the portio vaginalis, the cervical canal, 
and the body of the uterus prepares one to find different physical 
signs according to its situation. The association of hemorrhage, 
foul discharge, and pain should awaken a profound suspicion 
that should be satisfied only by careful examination. Carcinoma 
of the portio vaginalis is, as a rule, easy to recognize. It is 
accessible to the investigating finger, and is readily exposed to 
vision by the speculum. The most characteristic form is the 
cauliflower growth, which springs by a narrow base from one 
or the other lip, and may fill the vagina. It presents to the 
finger an irregular, nodular mass, which bleeds upon the slightest 
touch, is very friable, and is frequently covered by a greenish 
exudate or slough. The mass may vary from a nodule the size 
of a bean to a growth the size of a fist. Instead of an exuberant 
growth the disease may present an excavated cavity with in- 
durated wall and base and undermined edges. In diseases of the 
cervical canal the external os may present a crater-like opening 
or may appear healthy. In the early stage the disease of the 
cervical canal affords no external or apparent indication of the 
disease. The infiltration involves only the mucous membrane of 
the canal. 

If we follow the rule to secure an accurate examination of 
such cases, it may be necessary to explore the intra-uterine 
cavity. This procedure is best accomplished by the use of 
laminaria tents. These tents should be sterile, and should be 
removed from a saturated solution of iodoform and ether before 
their introduction. Tissue occupied by carcinomatous infiltrate 
will not readily dilate. The scrapings obtained by the curet will 
often show fragments which are easily broken or crumbled, in 
place of the long, thickened pieces removed in endometritis. The 
curet and, still better, the finger will disclose a roughened, in- 
durated canal, which is characteristic. In a very early stage the 
cervical cancer appears as small, indurated nodules, which later 
become friable. It should be recognized that cancer of the 
vaginal portion does not manifest a disposition to involve the 
cervical cavity early, which knowledge enables us to determine 
that the cervix remains free unless in advanced cases. In doubt- 
ful cases the suspected tissue, either in the form of scrapings or 
an excised piece, should be subjected to microscopic examination. 
The portion of tissue excised should involve both healthy and 



716 GYNECOLOGY. 

diseased tissue, when the transition from one to the other can 
be better studied. It is objected to the microscopic examination 
that it takes valuable time to prepare the specimens, but Smyly 
suggests the following two methods for rapid examination: First, 
a small piece of firm tissue is selected, dipped in mucilage, placed 
in a freezing microtome, partly frozen sections of which are cut, 
transferred to Miiller's fluid or to a 2 per cent, solution of potassii 
bichromas, and, after from a few minutes to an hour, stained 
and mounted. In the second method a piece of the tissue the 
size of a bean is placed in twenty times the quantity of methylated 
spirit or, preferably, in alcohol for a few hours, then a few hours 
in running water, dipped in mucilage, and sections made after 
freezing. The sections are removed from water to the slide, 
where they are stained with either picrocarmin or rubin and 
orange. These methods are too complicated for the general 
practitioner. 

Spiegelberg has emphasized the closer adhesion of the mucous 
membrane to the underlying tissue in cancer over that which 
exists in inflammation. Our diagnosis must comprise, naturally, 
the recognition of the presence of cancer, and, also, the extent 
of structure involvement and the probability for radical removal. 
Digital examination through the rectum affords accurate in- 
formation as to the extent of the disease in the parametrial tissue 
of the pelvis. Nests or nodules may be found upon the posterior 
surface of the broad ligament, which cause firm fixation by the 
extension of the disease to one or both broad ligaments. We 
should endeavor to distinguish between fixation from previous 
inflammatory trouble and cancerous infiltration. In the latter 
the involved surface is more irregular, presents small, hard 
nodules, and a more distinct limitation, which can be determined 
through the rectum. The latter examination can be more 
effectively accomplished with the patient under an anesthetic. 
A rectal examination should be a matter of routine. Twice I 
have found coexisting rectal cancer in women who otherwise 
would have been favorable cases for uterine extirpation. In 
neither of these patients did there seem to be any connection 
between the cancerous growth of the rectum and that of the 
uterus. 

The conditions which can be confused with cancer are : 

Chronic cervical catarrh with laceration. 

Papillary erosion of the cervix. 

Necrosis of fibroid polypus. 

Syphilitic ulceration. 

Partial retention of the products of conception. 

Chorio -epithelioma . 

Sarcoma. 



GENITAL TUMORS. 717 

In chronic cervical catarrh with laceration nature makes an 
effort to repair the injury, the increased weight of the organ 
and its situation lead to e version of the lips, and the fissures 
are occupied by hard, resistant tissue. The exposure of the 
tender cervical mucous membrane causes inflammatory changes, 
thickening and e version, obstruction of the ducts of the glands 
of Naboth, and the formation of Nabothian cysts. The surface 
not infrequently is covered with granular tissue, which readily 
bleeds upon the slightest touch; the patient consequently has 
increased bleeding during menstruation, more or less bleeding 
upon exercise, and bleeding following coition. The indurated 
surface with a tendency to bleed, the increased leukorrheal dis- 
charge, the nodular condition produced by the distended glands, 
might readily lead an inexperienced physician to believe that he 
had to deal with cancer. Indeed, many of these cases are so 
close to the border-line as to render it difficult to arrive at a 
certain conclusion. The treatment of the case will frequently 
remove the doubt. Puncture of the cysts and the application of 
caustics cause cicatrization of the surface, and demonstrate that 
it is not malignant. It has been said that Nabothian cysts abso- 
lutely contraindicate the existence of cancer, but cases have been 
observed in which Nabothian cysts are filled with their secretion 
in the immediate vicinity of cancerous degeneration. The ab- 
sence of tissue friable to the touch, the use of the speculum, and, 
when necessary, the examination of an excised piece should 
render the diagnosis of a benign condition positive. 

Papillary erosion of the cervix is sometimes mistaken for a 
carcinomatous ulcer, but the latter is covered with friable tissue 
and bleeds easily. In carcinoma the affected structure is raised 
above the level of the healthy cervix ; in erosion it is depressed. 
The latter has a regular outline, the carcinomatous ulcer an 
irregular, ragged line of demarcation. 

Necrosis of a fibroid polypus is a condition in which the sub- 
jective symptoms are very similar to those of cancer. I recently 
saw a patient, a widow, forty-five years of age, who was suffering 
from a profuse menorrhagia, from a copious foul-smelling dis- 
charge, and had been assured by her physician that she was 
suffering from an inoperable cancer of the uterus. The appear- 
ance of the patient and the odor in the room apparently justified 
the assertion; but a digital examination revealed a large mass 
filling up the vagina, which was firm and resistant, and could be 
turned about from one position to another. The lower surface of 
the mass was somewhat roughened, but its upper surface was 
smooth. The finger, carried well over it, could reach a distinct 
pedicle, which could be traced upward to the uterus ; the cervix 
was thinned, and at no place hard, indurated, or infiltrated; con- 



718 GYNECOLOGY. 

sequently, I had no hesitation in assuring her that she could be 
reheved. 

In necrosis of a fibroid situated within the vagina the diag- 
nosis is readily made. The firmer resistance, the recognition of 
a pedicle, the absence of any infiltration about the external os, 
and the smooth outline render its character certain. When the 
growth is situated within the cavity of the uterus, however, it 
may be more difficult. Here a sloughing fibroid causes hemor- 
rhage and a profuse offensive discharge, but the discharge is 
usually thinner, watery in character, and may contain particles 
of the growth. These particles are more in the nature of a 
slough. The uterus is larger in outline, the cavity of the 
organ is frequently open so that the finger can enter and come 
in contact with the mass which fills the uterus, and, by ma- 
nipulation, occasionally fragments of the tissue may be broken 
off and examined under a microscope, or often under macro- 
scopic examination the fibrous structure is recognized, which 
should exclude cancer. Dilatation of the uterus sufficient to 
permit the introduction of the finger discloses the cavity occu- 
pied by a mass which is more or less resistant, not friable, nor 
easily broken down. 

Syphilitic Ulceration. — Syphilitic ulceration should be readily 
distinguished from cancer by recognition of the fact that it does 
not present an excavated surface with indurated base and edges, 
that it is associated with evidence of syphilis in other portions of 
the body, and by the absence of friable tissue upon the ulcerated 
surface. Microscopic examination to fix the diagnosis is gener- 
ally unnecessary. 

Partial Retention of the Products of Conception. — The retained 
tissues may be the embryonic envelope, a portion of the placenta, 
or blood-clots, which, when retained, are subjected to infection, 
cause an exceedingly foul-smelling and offensive discharge, and 
their presence is a frequent cause of bleeding. The history of 
recent abortion or delivery, the dilated os permitting the intro- 
duction of the finger, and the recognition of the retained products 
by exploration determine the condition. The retained products 
scraped away, a smooth surface is left, which is the normal 
uterine wall. The absence of further irritation following cleans- 
ing of the cavity demonstrates its true character. 

Chorio -epithelioma presents a history of a previous abortion 
or labor within a few weeks or months, following which the 
patient suffers from profuse, irregular bleeding, which leads the 
physician to make a curetment in which there is a large amount 
of soft, friable tissue removed. This treatment arrests the hem- 
orrhage for a very brief time, when the conditions recur, and a 
second curetment will disclose the fact that the structure found 



GENITAL TUMORS. 719 

in the first curetment had been re-formed. The disease shows a 
marked tendency to early metastasis through the blood-vessels. 
The disease occurs in patients at an earlier age than carcinoma. 
The age of the patient, the history of previous pregnancy, the 
severe hemorrhages, the rapid development, and its recurrence 
should lead to its diagnosis. The structure can be differentiated 
from cancer only by the use of the microscope. This reveals that 
the material is epithelial, but it differs from cancer in the absence 
of the well-marked stroma. In this respect it resembles sarcoma, 
but differs from it in the fact that it is composed of epithelial 
and not of connective -tissue cells. The further investigation dis- 
closes that this epithelium is the product of fetal life and origi- 
nated from the covering chorionic villi, the syncitial cells. 

Sarcoma causes symptoms similar to those of carcinoma. It 
may be differentiated, however, when it affects the cervix by 
the polypoid masses projecting from it, sometimes grape-like in 
form. Where the disease involves the body of the uterus, the 
organ is likely to become much larger than is the case in car- 
cinoma. Sarcoma, however, is much more rare than carcinoma. 
The microscope affords the only means for arriving at a positive 
diagnosis. The structure of the sarcoma is homogeneous, and 
consists of connective -tissue cells, either round, spindle, or giant 
cells, without a well-defined stroma; they invade the walls of the 
blood-vessels and cause them to appear as mere sluiceways 
throughout the structure. In carcinoma the structure is nest- 
like with a well-defined stroma, the vessels are situated in the 
stroma and their coats are not destroyed. 

It is seen that the existence of carcinoma does not preclude 
the possibility of pregnancy. The occurrence of this complica- 
tion renders it important that we should study its course and 
be able to determine its presence. The diagnosis is rendered 
easier by comparison of the hard, firm, infiltrated carcinomatous 
parts with the softer, edematous, healthy tissue of the uterus in 
the pregnant condition. The carcinomatous nodules of the 
vaginal portion of the cervix may be recognized by touch, and 
often as intervening between the finger and the parts of the 
child. In some cases the initial stage of the malignant disease 
may be so slight as to be overlooked, and if the observer is in 
doubt as to the correctness of the diagnosis, a microscopic inves- 
tigation of excised tissue should be employed. More difficult 
even than the recognition of carcinoma is the determination of 
the existence of pregnancy in the earlier months. Pozzi claims 
that it is impossible to diagnose the existence of pregnancy with 
uterine cancer prior to the fourth month. A number of cases 
are recorded in which pregnancy was first recognized during or 
following a total extirpation. It can thus be readily understood 



720 GYNECOLOGY. 

why pregnancy can be overlooked in the second and third months. 
The earlier recognition of the condition is of extreme value, for 
observations have demonstrated the fact that the increased con- 
gestion which occurs in the uterus favors the more rapid develop- 
ment of malignant disease. It was formerly believed that the 
existence of pregnancy during cancer allayed or arrested the 
progress of the latter, to be accelerated subsequent to its ter- 
mination, but careful observation has demonstrated the fallacy 
of this view. On the contrary, the increased nutrition which is 
directed to the uterus by the occurrence of pregnancy favors the 
more rapid development of malignant disease. The recognition 
of the existence of carcinoma, as determined by the microscopic 
investigation of the excised tissue and the simultaneous enlarge- 
ment of the uterus, should cause the complication to be sus- 
pected. 

571. Duration of Cancer. — The duration of life in this disease 
is hard to fix, because we know scarcely anything of its first 
beginning. We have no means of knowing how long a period 
transpires between its origin and the ulceration which produces 
the first symptoms for which the patient is induced to consult 
the physician. The form of cancer is also a determining factor. 
The soft, medullary cancer is rapid in progress and destructive 
in its action. The final catastrophe occurs much sooner than in 
scirrhus. The earlier in life the disease develops, the more rapid, 
as a rule, will be its progress. The period of survival varies, 
according to different authors, between six months and two or 
three years ; in squamous-cell cancer, from three to four years ; 
in cylinder-cell cancer, from one to two and a half years. A 
somewhat longer period is ascribed to cancer of the body. 
The normal duration of life can be materially altered by thera- 
peutic measures. Cases are seen in which, after operation, 
months or years passed without any indication of relapse. 
This is true not only after radical operation, but the patient 
so improves after the arrest of hemorrhage and discharge by 
some palliative measure as almost to cause the patient and 
her friends to doubt the possibility of the disease being of so 
serious a character. 

572. Prognosis. — It is only necessary that one should study 
the clinical course of carcinoma to be convinced that the prog- 
nosis must be bad. The improvement of the prognosis lies, first, 
in the early recognition of the disease; second, in prompt resort 
to radical operation. The first provision requires its recognition 
even before the characteristic symptoms of the disease are mani- 
fest. A patient in whom the irritative conditions favorable to 
the development of malignant disease exist should be kept under 
observation, and during the period of greatest susceptibility 



GENITAL TUMORS. 721 

should be subjected to a quarterly, at least a semi-annual, exam- 
ination. Causes of special irritation should, as far as possible, 
be removed by appropriate treatment. Second, radical treatment 
should be understood as a procedure which will insure removal 
of the diseased structure within the limits of healthy tissue. 
Always to accomplish this, the operation must necessarily be 
early. The probability of rapid invasion of the deeper structure, 
and of the establishment of secondary nests more or less remote 
from the original site, is less marked in cancer of the body of 
the uterus than in that of the cervix or the vaginal portion. 
Cancer of the uterus in a woman prior to the age of forty years 
is more acute in its progress than in women of more mature 
years. The prognosis of the disease is materially affected by the 
thoroughness of the operative procedure and by the precautions 
which are exercised to prevent reinfection of the new wound. 
Our inability to determine when and to what extent metastasis 
has occurred renders us unable to fix the prognosis after operation 
with any degree of certainty in the individual case. An appa- 
rently hopeful one will soon relapse, and one for whom the out- 
look seems uninviting will remain for a long time relapse free, 
dependent upon obscure processes whose rationale we do not 
fully comprehend. 

The outlook for length of life of the patient suffering from 
cancer of the uterus is affected largely by the occurrence of 
pregnancy as a complication. The prognosis of pregnancy de- 
pends upon the kind and the course of labor and upon the 
general condition of the patient; above all, upon the extension of 
carcinoma. The more difficult the labor, the poorer the general 
condition of the patient, and the more progressive the disease, 
the more certain will be the unfortunate result and probable 
death. The outlook of the woman suffering from cancer with a 
pregnant uterus is far worse than for the nonpregnant, because 
pregnancy and labor occasion extremely dangerous results. The 
rapid progress of the disease during pregnancy, the severe trauma 
during labor, and the rapid carcinomatous degeneration of the 
tissue affect the result. Chantreuil reported that in sixty preg- 
nant carcinomatous diseased women twenty-five died during or 
shortly after childbirth. Cohnstein, in one hundred and twenty- 
six cases, saw seventy-two die. Hermann had one hundred and 
eighty cases in which seventy-two died. The uterine rupture 
alone had six victims out of Chantreuil's sixty cases; eleven out 
of Hermann's one hundred and eighty ; nineteen out of one hun- 
dred and twenty-six women, according to Cohnstein, died unde- 
livered — about 8.1 per cent, of all the cases. Under the uniform 
methods of treatment employed of late years, the mortality is 
somewhat decreased. It is now admitted that the treatment of 
46 



722 GYNECOLOGY. 

complications of pregnancy must be consigned to operative pro- 
cedure, either gynecologic or obstetric. Formerly the treatment 
was limited to artificial abortion and premature labor. But little 
experience, however, was required to demonstrate that such 
measures were ineffective. The course then advised was to pro- 
long the pregnancy as long as possible with a view to secur- 
ing viability for the child, and the obstetric operation became 
the important consideration. Later experience in the various 
methods of treatment has led to the following conclusions: (i) In 
cases in which the cancer has reached a stage where radical 
operation is impracticable every effort should be made to prolong 
the pregnancy until the child becomes viable; (2) where the 
patient, however, is recognized to have the disease in its early 
stages, with a reasonable hope for successful removal, the ovum 
should not for a moment be permitted to prejudice the chances 
for the mother, and radical operation should be undertaken 
without reference to the child. 

573. Treatment. — Our previous study of the anatomic struc- 
ture and progress of development indicates that cancer originally 
consists of a primary nest, from which invasion of the surrounding 
structures occurs. The rational treatment, then, consists in the 
removal of the diseased structure within healthy limits. Upon 
the extent of involvement will depend our ability to remove com- 
pletely the disease, and hence the division into two classes — 
operable and inoperable. The following scheme represents the 
methods of treatment which may be adapted to each class : 



/ I. Partial extirpation, Vaginal. 

1 r (a) Vaginal.' 

1 2. Total extirpation, \ (b) Abdominal. 

(A) Operable. ( ( (c) Sacral. 

/ ( (a) Cureting. 

\ 3. Palliative operations, < (b) Caustics. 

t (c) Cautery. 

(B) Inoperable. \ 4' Injections { [^^ Ckansing'!''''' 

i 5. Anodynes. 



574. {A) Operable. — (i) Partial Vaginal Operations. — As car- 
cinoma uteri largely preponderates in the neck, it is quite con- 
ceivable that the early operations were directed to the extirpation 
of that section of the organ involved. Von Grafenberg, as early 
as 1600, reported that the uterus had been normally extirpated 
in a number of cases, but it is most probable that the majority 
of these were amputations of the cervix, particularly as the 
subsequent continuance of menstruation is noted in several 
women, and, indeed, the birth of children. In the early cases 
hemorrhage was controlled by styptics, and many of the patients 
•succumbed to hemorrhage and sepsis. 



GENITAL TUMORS. 723 

Partial extirpation has remained, until the last fifteen years, 
the principal, if not the exclusive, operative method of combating 
carcinoma. It consisted in the removal of the diseased parts with 
knife or scissors, and the control of hemorrhage with the cautery 
or strong fluid caustic. The difficulty in controlling hemorrhage 
led to the employment of the chain or wire ecraseur, by which 
the diseased tissue is crushed off. A marked improvement was 
the employment of the galvanocautery loop — the galvanic loops 
placed upon the cervix above the margin of the disease, tightened, 
and the cervix amputated. This procedure has been extensively 
practised by C. Braun and Byrne, with extraordinary results. 
The latter has made the procedure still more effective by substi- 
tuting the galvanic knife for the loop. 

Neither the employment of the ecraseur nor the use of the 
loop can be considered as an ideal surgical procedure, for, with 
the first, injury of the neighboring organs can not always be 
avoided, and, with the second, it is not always possible so to 
place the loop that amputation of the vaginal portion of the 
cervix results with certainty in healthy tissue. A more progres- 
sive method was instituted by returning to amputation with 
the knife and union of the wound surfaces by sutures. The 
procedure was introduced by Hegar, who made a funnel-shaped 
incision. Schroder perfected supravaginal amputation of the 
cervix, a method capable of meeting all the requirements of the 
present partial uterine extirpation per vaginam. 

Amputation of the Cervix with the Galvanocautery Loop. — The 
preparation for vaginal operation (Section 119) is made, exercis- 
ing care to penetrate and disinfect the neck. The cervix is ex- 
posed with specula or retractors, seized with hook forceps which 
dip into the healthy tissue, and drawn upon, while the platinum 
loop is placed as high as possible, coming immediately under the 
transverse folds which indicate the position of the bladder, and 
is so tightened that it cuts into the tissue. As the excision pro- 
gresses the vagina is protected from heat by wooden plates and 
syringed several times with water in order to thus cool the 
tissues and preserve them from burning. The wire must be kept 
at a red heat in order that the surfaces shall be well scorched. 
The wire should be tightened slowly until the cervix is cut 
through. AVhen the operation is accomplished with due delibera- 
tion, there is no subsequent tendency to bleeding. The higher 
the wire is placed upon the cervix, the more probable it is that 
Douglas' pouch will be opened. The occurrence of such an acci- 
dent, however, requires no more consideration than to pack the 
cavity with iodoform gauze. By the employment of the galvano- 
cautery knife Byrne improved the operation. He cut around the 



724 GYNECOLOGY. 

vagina, separated it from the cervix, and was enabled to remove 
the latter at a higher level. 

Hegar's Operation. — The funnel-shaped amputation of the 
cervix described by Hegar is accomplished as follows: The 
cervix is fixed by double tenacula and drawn downward. A 
knife is introduced as far away from the limits of the disease 
as safety for the bladder and ureters will permit, and is carried 
about the cervix, held at such an angle as to cut out a cone- 
shaped mass, the apex of which would be high in the cervical 
canal. The hemorrhage is controlled by sutures and tamponade. 
Baker operated in a similar manner, but controlled the hemor- 
rhage with the cautery, while Van de Warker cauterized the 
surface with zinc chlorid. 

Schroder's operation is a supravaginal amputation, of which 
the following is a description : The cancerous portion is exposed 
by Simon's retractors. With a sharp curet all removable tissue 
is scraped away from the new formation until the curet reaches 
firm tissue, when the entire bleeding surface is scorched with 
a hot iron, the vagina being protected from the heat and fre- 
quently irrigated as the operation proceeds. The cervix is 
seized with a vulsellum and drawn downward as far as pos- 
sible. An incision — if possible, one centimeter from the dis- 
ease margin — is carried about the cervix; with the index-finger 
or a gauze pledget the bladder is bluntly separated from the 
anterior uterine wall. The bladder and ureters are thus shoved 
upward, when the anterior wall of the neck can be removed at 
a high level. In this operation Douglas' space is frequently 
opened, but the cervix is retained in connection with the lateral 
parametrium. The cervix is pulled to one side while with a 
Deschamps needle a ligature is passed as far away from the 
cervix as possible, tied firmly, and the tissue cut between the 
neck and the ligature. If the tissue is thick, a number of liga- 
tures may be applied, one above another, and when the op- 
posite side is likewise treated, the cervix is cut away. When 
necessary, all the cervix below the internal os can be removed. 
If Douglas' pouch is opened, the circumstance may be made 
useful in closing the parametrium, as the needle can be passed 
upon the finger, introduced through the opening. The cervix 
is then amputated at the level of the internal os. The section 
is made through the anterior vaginal wall to the cavity, and, 
before proceeding further, the anterior vaginal wall is stitched 
to the anterior cervical wall with from two to four sutures. 
The amputation is completed by cutting through the posterior 
wall, when the surfaces are sutured as in the anterior. A num- 
ber of sutures are now applied to the lateral portions of the 
wound to insure closure. The sutures should be carefully 



GEXITAL TUMORS. 725 

placed in the lateral angles in order to secure the uterine arteries. 
When they are ineffectually secured, hemorrhage may be free 
and threaten a fatal result. The patient can arise in from 
ten to twelve days and be discharged after from eighteen to 
twenty days. 

The high amputation of the cervix has had many advocates, 
who champion it in preference to extirpation as being safer 
and less prone to subsequent relapse. The employment of 
the galvanocautery knife may produce a beneficial influence 
in the destruction of cancer nests which would be overlooked 
by the scalpel. An objection to the operation is that the cer- 
vical opening may contract and become closed, causing subse- 
quent distress, and necessitate further operative procedure 
to relieve the dysmenorrhea or hematometra. Cases of preg- 
nancy have been reported, but the difficulty in labor was so 
great, because of the scar tissue, that operative delivery was 
required and the patients died. Similar experience has been 
observed in the Hegar operation, owing to the difficulty in 
introducing the sutures. All these disadvantages are avoided 
by the Schroder operation. 

The investigations of Seelig have demonstrated that in- 
fection has been carried through the lymphatics to the cervix, 
and even to the body, of the uterus. Such an occurrence would 
render anything less than extirpation of the entire organ of 
no service, and we have no means of determining when it has 
taken place. An additional reason for preferring the entire 
extirpation is that the cicatricial tissue is always irritable, and 
is a source of danger in a woman predisposed to undergo malig- 
nant change. The removal of the uterus and ovaries brings 
about a lessened congestion of the pelvic tissues, and will cer- 
tainly leave the patient free of subsequent periodic engorge- 
ment of the pelvic structures. The cases suitable for the partial 
operation are infrequent. 

575. Total Extirpation of the Uterus. — Isolated examples 
of total extirpation of the uterus have been mentioned as hav- 
ing occurred at various times during the eighteenth century, 
but it remained for Freund, by the abdomen, and Czerny, by 
the vagina, to formulate procedures which have led to the 
more complete and satisfactory methods of the present day. 

Total extirpation may be undertaken in one of two stages 
of development: first, when no evidence of involvement of 
the parametrium exists, when the object is to eradicate the 
disease by ablation of the organ and of surrounding portions 
of vagina and parametrium, or to operate within healthy tissue; 
second, when there is some involvement of the parametrium 



726 GYNECOLOGY. 

with fixation of the uterus. The latter operation is not cura- 
tive, but may amehorate symptoms. 

In performing the radical operation two purposes should be 
kept in mind: (i) To keep beyond the confines of the disease 
by operating in healthy tissue; (2) protect the patient from 
any possibility of reinfection. 

1. The recognition of the processes of development and 
the extension of cancer make it absolutely uncertain in any 
individual case that this purpose has been accomplished. The 
operator is absolutely unable to determine prior to operation 
that circulatory or irritative extension has not involved the 
parametrium beyond the safe limits of operation. In some 
this transmission may occur early in the disease, in others 
late, so that in a woman with but slight involvement and no 
demonstrable evidence of extension a favorable prognosis is 
usually given. However, not infrequently in these cases the 
physician is horrified to find a recurrence after a very brief 
period, while in others the entire vaginal cervix maybe destroyed, 
and he operates radically, though only with a hope of amelio- 
ration, but the patient remains free from recurrence for years 
or even permanently. 

2. The possibility of reinfection or of the transplantation 
of portions of cancerous structure upon a healthy wound and 
the reproduction of the disease from it is questioned. Such 
a view would seem a reasonable explanation for the redevelop- 
ment of cancer in a wound where microscopic investigation 
indicated that the operator was well beyond the confines of 
the disease. The opponent of infection, however, justly in- 
stances the possibility of metastatic nests in the parametrium, 
discoverable only by the microscope, from which the recur- 
rence has followed. Such statements for the vicinity of the 
wound are difiicult to combat, but if, in a single case, the dis- 
ease can be transplanted to the abdominal wound in an abdom- 
inal hysterectomy, it should be considered proof that such 
reinfection may occur, for that region would be entirely out of 
the usual route for metastatic extension. Such an infection 
came under my observation in the practice of one of my col- 
leagues, in a young unmarried but not childless woman. Within 
two months of an abdominal hysterectomy nodular masses 
were observed in the abdominal wound, which subsequently 
progressed. In two cases of my own experience transplantation 
has occurred. In both of these patients there was extensive 
involvement and obstruction of the cervix by a squamous- 
cell carcinoma. In the first patient a sinus remained in the 
abdominal wall following a stitch abscess, in which prolifera- 
tion of the epithelium occurred. This resulted in a spreading 



GENITAL TUMORS. 727 

sore, involving the tissue circumjacent to the abdominal in- 
cision. As this patient had pelvic involvement as well, the 
possibility of continuous involvement must, of course, be con- 
sidered, although I was apparently able to excise the infected 
abdominal tissue without opening the peritoneal cavity. The 
second patient, an unmarried woman, underwent operation 
June 19, 1900. The entire cervix w^as involved in a cauliflower 
growth to such a degree that her attendant, a surgeon of con- 
siderable experience, questioned the advisability of operation. 
She w^as exceedingly anemic and broken down by repeated 
hemorrhages. She had no control of nausea and vomiting for 
five days subsequent to the operation. At the close of the 
week it was found that all the sutures had cut through, the 
wound was gaping and the intestine protruding. The wound 
had been closed with silkworm-gut sutures for all the tissues 
above the peritoneum, and continuous chromic catgut for the 
latter and the aponeurosis. The intestines were packed back 
with gauze, and a week later the wound was closed with through- 
and-through silkworm-gut sutures under cocain anesthesia. 
The patient left the sanatorium five weeks subsequent to the 
performance of her operation, with good union in the abdominal 
wound. Much to the surprise of her attendant and myself 
she enjoyed, barring a very small A'entral hernia, excellent 
health for over two and one-half years. Three months ago 
she began to have discomfort, and swelling in the line of the 
wound, and a lump could be felt which was thought to be a 
strangulated and inflamed projection of the omentum. How^- 
ever, the mass gradually increased in size and became painful, 
and, therefore, a provisional diagnosis of recurrent malignant 
disease was made. This was excised June i8, 1903, three years 
from the date of her previous operation. A mass of infiltrate 
as large as a hen's egg occupied the center of the cicatrix. The 
omentum and a portion of the ileum were adherent and had 
to be separated with scissors; a portion of the intestine was 
also involved in an annular band of tissue, for which three 
inches were excised and united by an end-to-end anastomosis. 
Careful examination failed to reveal any other evidence of the 
disease, the pelvis disclosed no sign of any infiltrate or glandular 
enlargement, although careful observation was made. It may 
seem that the two and one-half years which intervened before 
the development of this growth would argue against trans- 
plantation, but is it any more difiicult to consider transplanted 
cells as lying latent and inactive in this area than those which 
have been transmitted to the parametrium to develop within 
the five years, a period which all authorities admit should 
transpire before a case can be pronounced as cured? 



728 



GYNECOLOGY. 



Whether we accept or reject the theory of infection, the 
precautions taken to prevent it are only such as will be of ser- 
vice in rendering the parts sterile and in preventing infection 
from pathogenic germs, which every one will admit are present. 

Preliminary Treatment. — In every extirpation of the organ, 
whether by the vagina or the abdomen, in addition to the prepa- 
ration indicated in Section 119, precautions should be exercised 
to remove all diseased and disintegrated tissue. The surface 




Fig. 493. — Formation of Flap to Cover Diseased Surface Preliminary to 

Operation. 



should be gone over with a sharp curet, all loose and ragged 
edges trimmed with scissors, and the entire surface thoroughly 
scorched with the thermocautery. Sutures should then be 
placed to close up the diseased surface. If the entire vaginal 
cervix is more or less involved, incisions should be made upon 
each side which will permit flaps to be turned down and sutured 
over the diseased structures. The vagina should be continu- 



GENITAL TUMORS. 729 

ously irrigated during the process of closing off the diseased 
surface and carefully sponged with a solution of sublimate in 
alcohol (i : 500). 

576. Vaginal Hysterectomy.— Many isolated cases of ex- 
tirpation of the uterus per vaginam are found in the literature 
of the last century, notably those of Langenbeck and Sauter- 
Recamier. Czerny, on August 12, 1873, revived the opera- 
tion. The operation has also been variously modified. The 
following method should be pursued: 

1. After the preliminary preparation directed (Sec. 119) 
place the patient in the lithotomy position, expose the uterus 
with an Edebohls speculum and lateral retractors, make traction 
upon the cervix with double tenaculum and vulsellum or a silk 
loop passed through it, draw it down as near to the vulvar orifice 
as possible, and close the cervix by sutures, making flaps where 
necessary to close in the diseased tissue. Sterilize the hands, 
and the instruments so far used. 

2. Separate the cervix with scissors, knife, or thermocauter}^ 
from the vaginal w^all by an ovoid incision, extending it as far 
away from the diseased tissue as safety for the bladder and 
ureters will permit. This can be carried higher on the pos- 
terior surface without fear of injuring the rectum. The thermo- 
cautery knife has the advantage that it decreases hemorrhage 
and prevents immediate union, thus favoring better drainage. 

3. Push back the bladder from the anterior wall of the 
uterus and from the broad ligaments. Where desirable to re- 
move a large portion of the parametrium, expose each ureter 
and place upon it a traction ligature, as suggested by Bovee, 
when the uterine artery can be traced out and ligated near 
its origin. 

4. The fundus of the uterus is turned down through the 
anterior vaginal fornix, the broad ligament seized upon the 
left side, crushed by the angiotribe, ligated in the groove, and 
the uterus separated. Repeat this process upon the right. 
Seize any bleeding vessels with hemostatic forceps and ligate 
them. 

5. Unite the peritoneal surfaces with a continuous catgut 
suture, taking the precaution to secure at either angle the stum^p 
of the broad ligament. Cleanse the cavity and loosely pack 
the vagina with iodoform gauze. 

iVll sutures should be of catgut, as silk is likeh'^ to become 
infected and produce a discharge and maintain a sinus until 
it comes away, which may require months, unless previously 
removed. Such a patient will be in constant apprehension 
that the disease is returning. The disposition of the ovaries 
and tubes will depend upon their situation and the extent of 



730 GYNECOLOGY. 

the disease. If they are easily displaced downward, they 
should be removed; if high up, requiring considerable mani- 
pulation to displace them, they should be permitted to remain, 
as they cause no trouble. With the completion of the opera- 
tion the wound should be carefully inspected for any bleed- 
ing vessels, as it is not impossible that a ligature may slip from 
the stump and a fatal hemorrhage result. Any bleeding points 
should be picked up and secured with separate ligature. 

The treatment of the wound will depend on the condition 
of the patient. Thus, if the patient is very much debilitated 
and it is undesirable to keep her long under the influence of 
an anesthetic, the wound may be packed between the stumps 
with iodoform gauze, carrying the latter sufficiently high to 
prevent the intestine from coming in contact with the raw 
surfaces. The gauze packing is lightly placed in the vagina 
and the vulva covered with a pad. This packing, when the 
blood control has been complete, may be permitted to remain 
for from four days to a week. Upon its removal the cavity 
is irrigated with a i : 2000 formalin solution, and may be lightly 
repacked, although the packing should not be carried so high 
as the first portion. The anterior and posterior walls of the 
vagina are thus permitted to fall together and become adherent. 
If there is no tendency to displacement of the viscera down- 
ward and the belly of the patient is not distended, the gauze 
need not be replaced, but we subsequently content ourselves 
with irrigation. In relaxed vagina, or when the condition 
of the patient will permit of more time for the operation, the 
ends of the broad ligaments are preferably united and the stumps 
drawn well into the vagina; the sides of the vagina are united 
to each stump by a deeply passed suture, which, when tied, 
holds up the vagina and avoids its subsequent relaxation for 
want of support. The patient should be confined to bed for 
two weeks; frequently cases are permitted to rise earlier than 
this, but the long rest in bed is no disadvantage. The pelvic 
floor is firmer, and is less likely to be split and subsequently 
to prolapse. 

Various modifications of the operation have been suggested. 
Three years after Czerny introduced it, Sanger was able to collect 
thirteen different methods of operating, and with each year 
subsequent various modifications have been suggested. Mikulicz 
was the first to use the curet. Billroth and Olshausen added 
scorching the surface with the thermocautery ; others, in addition, 
cauterized with carbolic acid or chlorid of zinc, or used iodo- 
form, liquor ferri chloridi, alcoholic bromin solution, and ab- 
solute alcohol. Tauffer made his preliminary preparations 
several days before the operation, and Leopold advocated 



GENITAL TUMORS. 731 

disinfection as the first step. Schauta began the operation 
with the thermocautery. Bottini, Wecchi, and Calderini am- 
putated with the galvanocautery loop, and followed with ex- 
tirpation. When cancer is situated high in the cavity of the 
uterus, antiseptic syringing is practised, the cavity packed 
with iodoform gauze, and the os closed over it with sutures 
or with clamp forceps. In order to limit the discharge of secre- 
tion in carcinoma of the body, Schauta introduced a tupelo 
tent into the cervix. This tent was somewhat constricted in 
the middle from perforation, and a thread was introduced, 
the ends of which were armed with needles. These needles 
perforated the cervical canal anteriorly and posteriorly, and 
the ends of the suture were tied over the end of the tent. The 
swelling of the tent acted as a plug to the cervical canal. Mac- 
kenrodt introduced the formation of flaps from the anterior 
and posterior vaginal surfaces, which we have described. Lan- 
dau advocated an ovoid incision, the posterior surfaces some- 
what higher than the front, as such an incision gave greater ac- 
cessibility to the operation field. Doyen lengthens the circular 
incision by one right and left, in order to create a still larger 
opening, and especially to be able to separate about the bladder 
and the ureters more securely. Fritsch incised both sides of 
the vagina; the base of the broad ligament is cut and tied, so 
that in this manner the uterus is easily movable and readily 
drawn down before the cervix is separated from the anterior 
and posterior union. Schatz opens into Douglas' space; then 
the uterus is completely freed from its lateral union, and, finally, 
the bladder is separated from the cervix. The ureters have 
been injured in this method of operating. Billroth separates 
by degrees the broad ligament, ligates the individual vessels, 
and fastens the broad ligament in a properly prepared clamp 
forceps. Schroder drew the uterus through the opening of 
Douglas' space into the vagina. This procedure is not always 
performed with ease. Fritsch rotated the uterus through the 
anterior peritoneal opening. Olshausen operated with the 
uterus continually in situ, and endeavored to separate it first 
on that side which showed the least invasion by cancer. Corradi 
and P. Miiller rendered removal of the uterus easier by dividing 
it into two portions by a sagittal section, and then removing 
each half singly. Kelly divides it into four or more. This 
procedure, without question, renders the removal of the uterus 
more easy, but if we believe in the reinfection of the wound, 
it greatly increases the danger. The ligation of the broad 
ligaments has also given great variety of procedure. Some 
ligate small sections; others ligate in mass. Olshausen, in the 
beginning, attempted to surround the broad ligament with a 



732 GYNECOLOGY. 

single ligature, but the sloughing stump would slip out from 
the ligature and considerable hemorrhage result. Liebmann 
attempted to ligate the parametrium in such a manner that 
the ligature is knotted on the vaginal mucous membrane in 
order to limit its slipping. The superior part of the broad 
ligament, with the spermatic vessels, repeatedly slips from 
the ligature and requires supplementary ligation, which is 
accomplished with great difficulty. Veit fastens the superior 
part of the stump with hook forceps and ties the ligament be- 
hind them. 

With regard to the removal of the ovaries there has been 
considerable discussion. Czerny, in his first case, removed 
the appendages supplementary to the removal of the uterus. 
Schroder, Olshausen, and others leave them when no indication 
of disease is found. Von Teuffel and Kaltenbach urge their 
removal; the latter emphasized the possibility of infection 
of the peritoneum by leaving inflammatory diseased portions 
of the tube. The retention of the appendages in carcinoma 
of the uterine neck is not found to favor the appearance of 
relapse. The course of the lymph-channels arising from the 
cervix has no relation to the appendages of the uterus. They 
should always be removed whenever pathologic alterations 
are recognizable. After Reich, in several cases of carcinoma 
of the body, had demonstrated cancerous disease of the ovary, 
the removal of the appendages was advocated in all cases, 
in this form of uterine cancer. Formerly surgeons employed 
irrigation freely with strong antiseptics during the early part 
of the operation. To-day, the majority of gynecologists, after 
radical disinfection of the field of the operation, proceed with 
sterilized instruments without irrigation. Irrigation should 
be employed only when necessary to cleanse the field, and it is 
better then to use nothing stronger than normal salt solution 
or a I per cent, saline solution. 

The vaginal operation will be especially difficult if the canal 
is narrow and rigid or the uterus very large. Under such cir- 
cumstances the majority of operators have incised the vaginal 
wall or the paravaginal tissue, by which procedure the lumen 
of the vagina is considerably increased. Von Winckel, in one 
case with enormous narrowing of the vagina and a large uterus, 
split the entire rectum and rectovaginal septum up to the vaginal 
vault. The large vaginorectal wound was sutured with silk, 
and recovered by primary intention. Duhrssen made a deep 
vaginal incision, which penetrated from the vaginal vault and 
completely opened the ischiorectal cavity and the entire vagina. 
Section on the right side penetrated the vagina, and also the 
rectum, to the depth of six or seven centimeters. By this 



GENITAL TUMORS. ' 733 

incision not only the vaginal tube, but also the surrounding 
muscular structure, the levator ani, and the constrictor cunei 
are separated. The direction of the incision is in the middle 
line, between the tuber ischii and the anal opening. By such 
an incision the entire field of the operation is incidentally in- 
creased, and the resistance of the soft parts of the pelvic cavity 
is removed. The hemorrhage from the vagino-intestinal in- 
cision is either controlled by ligature or through pressure of 
retractors. After the removal of the uterus the wound is closed 
by sutures. After such an incision relapses have occurred 
in the scar tissue, which are evidently infection relapses. Schu- 
chardt creates a still larger accessibility to the field of opera- 
tion by opening more widely the ischiorectal cavity. He makes 
two accessory incisions. One splits the entire lateral vaginal 
wall, from below to the neck; on the other side a long vaginal 
incision from behind progresses to the sacrum, and encircles 
the rectum bow-like, in an incidental sagittal section. The 
long incision is made upon the side in which the parametrium 
is strongly involved, and extends to the outside of the convex 
bow at the side of the anus. The extirpation of the uterus 
in these operations differs from the usual vaginal extirpation 
only in that the parametrium has been opened up so that some 
cancerous nodules can be removed therefrom without exposure 
of the ureters. The vagina is closed from above downward 
by knotted suture. 

While it is without question that these extensive vaginal in- 
cisions afford greater freedom in our manipulation of the uterus, 
the ease with which the uterus can be reached from above 
would seem to contraindicate such a method of procedure, 
but much more by the increased danger of reinfection of the 
parametric tissue that must be associated with it. In order 
to be able to remove larger portions of the parametrium with 
safety Pawlik, Kelly, and Clark introduced catheters into the 
ureters to render their position more definitely determined and 
to permit with safety the removal of larger portions of the 
endometrium. The ureters can be dissected out as suggested 
by Bovee; the catheter in one case was broken off, and the 
patient died. Its employment inflicts more or less trauma and, 
therefore, predisposes to infection. Mackenrodt, in total extir- 
pation, cuts about the vagina some distance from the portio 
and prepares anterior and posterior flaps, which are drawn 
over the portio and sutured so that the diseased tissue is com- 
pletely covered. He splits the anterior vaginal vault by a 
median incision from the urethral swelling to the circular in- 
cision. The accessibility of the operation fleld is still further 
increased by a deep vagino-intestinal incision. The bladder 



734 GYNECOLOGY. 

is dissected from the cervix, and especially from the broad 
ligaments, and therewith the ureters are separated some dis- 
tance ; and, finally, the uterus, with as large a portion as possible 
of the parametrium, is extirpated. The peritoneal wound is 
closed after the contraction of the stump, the vagino-intestinal 
incision narrowed by suture, and the vagina, with the supra- 
vaginal wound, packed with iodoform gauze. Later, Macken- 
rodt performed an operation in which the extirpation of the 
uterus and of the greater part of the vagina was accomplished 
with the hot iron. He believes that a larger extent of the 
vagina must be removed than is customary, because we do not 
know that a latent contact infection of the vagina does not 
already exist. He performs the operation as follows: 

With cutting instruments, Paquelin cautery, or galvano- 
cautery the entire vagina, or at least the upper half of it, is 
separated; a vaginorectal incision is made which extends to 
the portio and lays open the operation field; then the vagina 
is seized with forceps and separated downward by hot iron. 
If the upper part of the vagina only is removed, we begin with 
a circular incision in the middle of the vagina. After extirpa- 
tion of the vagina the portio is secured with forceps and Douglas' 
cavity is opened with a hot iron. The bladder and the broad 
ligaments are separated from the cervix by a properly con- 
structed shovel forceps, drawn as far as possible to the outside, 
and separated by the cautery. After the separation of the 
base of the broad ligament of both sides spurting vessels are 
seized with Koeberle forceps, which are placed in the higher 
part of the broad ligament, separated by the cautery, and the 
stump scorched. The now very movable uterus is easily in- 
verted. The upper parts of the broad ligaments are fastened 
with Richelot's clamps and a ligature is placed on each side, 
after which the separation of the stump results. After the 
removal of the uterus the rectovaginal incision is closed by 
sutures, when, in spite of the scorching, primary union is usually 
obtained. The perineum is not sutured. The burned cavity 
is filled with iodoform gauze. Elevation of temperature follows. 
Of ten cases subjected to this operation, two suffered from 
sepsis, 

Byrne has removed the entire uterus by the galvanocautery, 
but used the knife instead of the loop. Winter and Frommel 
combat the possibility of the danger of contact infection of 
the vagina being great enough to justify such a procedure. 
Czerny, Franck, and others have pursued the method suggested 
by Langenbeck of separation of the uterus from its peritoneal 
envelope, and the several resulting tears in the peritoneal cover- 
ing were united by sutures. This operation is sometimes very 



' GENITAL TUMORS. 735 

easily done, but in others is extremely difficult. Richelot and 
Pean advocate the use of clamps instead of the ligature. The 
preliminary steps of the operation are performed similarly 
to those already described. After opening the peritoneum in 
front of and behind the uterus, the organ is held by the broad 
ligaments, through which enter the uterine and ovarian arteries. 
Clamp forceps are applied at each side of the cervix, upon about 
one-half of the broad ligament, and the structure is cut between 
the cervix and the clamp. The uterus is drawn down, if pre- 
ferred, and the fundus is brought forward and through the 
anterior fornix; clamp forceps are applied from above upon 
the remaining portion of the broad ligament. The section 
between the clamp and the uterus frees that organ, which can 
be removed. The clamps are then held apart, the surfaces 
are separated by retractors, and careful inspection is made to 
determine that all bleeding vessels are controlled. Any spurting 
vessels should be secured with smaller clamp forceps or the 
arteries should be ligated. The clamps are held apart and iodo- 
form gauze is carried into the vaginal canal between them 
to the point at which the peritoneum has been separated, and 
is loosely packed between the clamps. The gauze should be 
carried over the end of the clamps, so that the coils of intestine 
shall not impinge against them and become injured. The 
operation has the advantage that it can be performed very 
expeditiously, and requires much less time than the application 
of the ligature. It has the disadvantage that the tissue within 
the grasp of the clamp undergoes sloughing, causes a foul dis- 
charge, an offensive odor, and sloughing tissue which endangers 
the infection of the peritoneal cavity. The convalescence of 
such patients is usually attended with considerable elevation 
of temperature. 

Tuffier reports twenty-seven cases of vaginal hysterectomy 
without the use of forceps or ligatures. The uterus was bisected, 
one-half drawn out of the vulva, the finger passed behind the 
upper part of the broad ligament, and the included tissue grasped 
between the blades of a powerful clamp, the angiotribe, which 
is tightly screwed. The tissues are thus crushed and the artery 
is occluded. After the crushing of the tissues the ligament 
is cut through and the upper part of the broad ligament crushed 
in a similar manner. It is very important that the handle 
should be secured as tight as possible and the blades kept in 
the axis of the vagina. In none of the cases reported had any 
accident occurred during the operation, and absence of hemor- 
rhage was particularly noted. This procedure is also advocated 
quite strongly by Dr. Newman, of Chicago. Dr. Downes, of 
this city, has greatly improved upon this miethod by the use 



736 GYNECOLOGY. 

of electro-?iemostasis. The late Dr. Joseph Eastman placed 
the patient in the Sims position, stretched the anus to allow 
greater readiness of access to the pelvic cavity, retracted the 
perineum with a Sims speculum, and made an incision about 
the uterus, which opened the Douglas culdesac posteriorly 
and between the bladder and uterus anteriorly. He then 
passed a curved staff over the broad ligament by which a liga- 
ture was carried and the broad ligament secured en masse, 
then over it was passed a pair of interlocking forceps by which 
the broad ligament was constricted, preliminary to its being 
severed, after which the ligament could be ligated in sections 
or the clamp permitted to remain. The other broad ligament 
was treated in a similar manner. The advantage he claimed 
for this procedure was greater security and control of hemor- 
rhage, and that the vagina was held at a lower level and its 
prolapse prevented. The position of the patient, with the pre- 
liminary dilatation of the anus, gives greater freedom of access 
to the uterus. 

577. Accidents of Vaginal Total Extirpation. — The most 
frequent injury is that of the bladder, which can take place 
in various ways. Thus, it may occur in the blunt separation 
from the anterior cervical wall. The danger of this becomes 
the greater, the more closely the new formation has approached 
the bladder. If it has passed over on to the external layer 
of the bladder- wall, we may very readily puncture the bladder 
in the most careful separation. When the bladder is infiltrated, 
the preferable plan is to cut out the diseased tissue and close 
the opening by sutures. Injury of the bladder is recognized, 
however, most frequently for the first time at a longer or shorter 
period after the operation, when a part of the urine is lost through 
the vagina. Either a small bladder injury has been overlooked, 
or, what is probably more frequent, the bladder has not been 
sufficiently separated from the ligament, and in placing the 
ligatures upon the parametrium a portion of it is fastened in 
the ligature, so that a slough of the affected bladder- wall occurs. 
A spontaneous closure not infrequently results from the scar 
retraction. When it has not closed, the repair of the fistula 
must be undertaken by operation. Kaltenbach claims that 
injury of the urinary apparatus occurs in about 10 per cent, 
of all cases; this, for the last few years, should be too high. 
An injury of one or both ureters is occasionally observed. The 
injury can be avoided if the bladder and ureters are well pushed 
back. It does not require the previously mentioned sounding 
of the ureters to avoid ureteric injuries. One should exclude 
cases from operation in which the parametrium and the sur- 
roundings of the ureter are infiltrated with carcinoma. In such 



GENITAL TUMORS. 737 

cases the shoving back of the ureter is exceedingly difficult, and 
not infrequently is associated with injury. The most serious 
injury of the ureter consists in the application of a ligature 
upon it. Ligation of both ureters is, without question, fatal, 
and the ligation of one manifests considerable injury. Schatz 
does not believe the ligation of one ureter necessarily unfavor- 
able, as the other kidney performs increased duty. He also 
believes that in one case after ligation of the ureter the canal 
again became penetrable a few days later. A number of operators 
have had to remove the corresponding kidney as a result of 
the ligation of the ureter. Zweifel, in double-sided ureteric 
ligation forty-eight hours after the operation, loosened the 
ligatures on the one side, and the strongly swollen ureter was 
made accessible again to the bladder; but as urine retention 
continued six days after the operation, the ligature on the 
other side was removed and the restoration of the ureters at- 
tained. 

Injuries of the rectum are much less likely to occur. They 
result only from especially unfavorable relations, as in adhesions 
of the rectum to the uterus. Frommel reports a case in which, 
in an attempt to open Douglas' space, the adherent rectum was 
injured, and, in spite of the most carefully introduced sutures, 
he lost the patient from septic peritonitis. In rare cases com- 
munication between an intestinal loop and the vagina, with 
involuntary fecal discharge, has occurred, most generally from 
relapse in the operation scar, by which the carcinoma extends 
upon an adherent loop of intestine. Numbers of cases are 
reported in which ileus results from adhesions in the open peri- 
toneal w^ound. In symptoms of ileus the intestinal loop should 
be separated from the vagina after opening the wound. If this 
fails, an artificial anus should be made or the affected loop of 
intestine should be resected. 

578. Abdominal Hysterectomy. — The first systematic opera- 
tion for the removal of a uterus for malignant disease through 
an- abdominal incision was performed by W. A. Freund, on the 
30th of January, 1878. The operation has undergone a number 
of modifications since its introduction by him. After preliminary 
preparation (Sections no to 120) the operation is performed as 
follows : 

I. The patient is placed in the lithotomy position, the friable 
tissue is removed from the cervix with the finger and spoon 
curet, all loose and ragged edges are trimmed with the scissors, 
the surfaces seared with the thermocautery and the lips sutured 
to close in all infected tissue. Where this cannot otherwise be 
accomplished, flaps should be dissected up. Before proceeding 
further, the hands and instruments should be resterilized. 

47 



738 GYNECOLOGY. 

2. The patient is placed in the Trendelenburg posture and 
an incision made in the median line from three centimeters 
above the symphysis to a short distance below the umbilicus, 
through which the intestines are pushed toward the diaphragm 
and walled off by gauze. 

3. The uterus is secured by a double tenaculum and vulsellum 
forceps or sutures which have been passed through the fundus, 
drawn up, and each broad ligament clamped, one blade of the 
clamp being passed through the ligament in such a way as to 
secure the round ligament. 

4. Cut the broad ligaments internal to the clamps, secure 
bleeding from the uterine side by hemostatic forceps, join the 
extremities of the broad ligament incision by one through the 
anterior peritoneum above the bladder, and strip it and the 
bladder away from the cervix and broad ligament. 

5. Find and secure the uterine artery upon each side with 
hemostatic forceps and cut between them and the uterus. 

6. Tilt the uterus to one side and open into the vagina, 
making sure the opening is well below the infected area. Through 
this opening the cervix can be followed around and severed from 
the vagina. 

7. The clamped vessels are ligated, the uterine by simple 
chromic catgut ligature, the ovarian en masse, after being crushed 
with the angiotribe. 

8. The surface is carefully inspected for bleeding vessels and 
infected glands, the peritoneal folds are stitched over the vagina 
with a continuous chromic catgut suture, inverting all ligated 
stumps into the vagina. 

9. Remove all gauze pads, cleanse the pelvis and close the 
abdominal wound, cleanse and apply dressing. Where the con- 
ditions make it desirable, after stripping back the anterior peri- 
toneum and bladder, the broad ligament can be spread out, the 
uterine artery traced outward and ligated near its source, the 
ureters raised, held to one side by traction ligatures, and a 
larger portion of the parametrium removed. 

The vaginal opening can be packed from above with iodoform 
gauze, an end of which is carried into the vagina, while the 
portion above covers the injured surfaces and prevents the con- 
tact of intestines. This gauze should be permitted to remain 
from four to six days, until the peritoneal surfaces have been 
closed over the vagina, and have made it an extraperitoneal 
surface. Some surgeons prefer to suture the peritoneal flaps, 
and loosely pack the wound from the vagina with iodoform gauze. 

In Freund's first procedure the broad ligaments were ligated 
external to the appendages, a second ligature was placed on the 
portion of the broad ligament which included the round ligament. 



GENITAL TUMORS. 739 

and a third secured the base of the broad hgament by being 
introduced from the vagina through a trocar needle which 
Freund devised for the purpose. The last ligature was tied upon 
the base of the ligament as firmly as possible. In this way 
three ligatures were inserted, one under another. The other 
broad ligament was secured in the same manner. The perito- 
neum above the bladder fundus was cut transversely upon the 
anterior uterine wall. A similar section was made upon the pos- 
terior wall, somewhat lower, and these wound margins were 
united with a silk loop after the removal of the uterus. The 
uterus was separated by knife or scissors. Hemorrhage from 
small vaginal arteries was controlled by ligation. All the liga- 
tures were carried into the vagina, and by traction the stump 
was drawn down. This dragging made the peritoneum of the 
bladder approach that of the posterior wall of the pouch of 
Douglas. These two walls could be united by continuous catgut 
suture. A most careful toilet of the peritoneum was accom- 
plished, the eventrated intestines were returned, and the belly 
wound was closed with sutures. The sutures that were pushed 
into the vagina could be removed by traction at the end of 
three weeks. The greatest danger of the operation was infection 
of the peritoneal cavity. 

This operation has undergone various modifications. Crede 
proposed to resect a part of the anterior pelvic wall several days 
before the operation, but found no imitators. A. Martin made a 
moon-shaped abdominal incision from the one anterior superior 
spine to the other, by which he hoped to be better able to keep 
the intestines in the abdominal cavity. He has not continued 
the procedure. The separation of the bladder from the uterus 
prior to the introduction of the base sutures has been a great 
improvement, decreasing the danger of injury of the bladder and 
of ligation of the ureters. Simpson, of New York, was the first 
to isolate and tie the uterine artery. Kuhn raised the uterus by 
means of the colpeurynter in the vagina, and made it more acces- 
sible. Eastman accomplished the same thing by a grooved staff 
through the posterior vaginal fornix. Bardenheuer advocates 
leaving open the peritoneal wound for drainage, but his results 
were not such as to make the plan acceptable. 

Modifications of the operation are, first, to make an incision 
through the vagina around the cervix ; pack the cavity with iodo- 
form gauze and complete the operation from above. Another is : 
separate the front and back, open into the vagina, and complete 
the operation by the application of clamps to the broad ligament. 
Veit operated by ligating and cutting the broad ligaments as far 
as the vault of the vagina; then he completed the operation 
through the vagina. Gubarroff, of Moscow, advocates the ab- 



740 GYNECOLOGY. 

dominal procedure, because of the impossibility of the removal 
of lymph-glands and the tissue at the base of the broad ligament 
in vaginal total extirpation. 

In marked involvement of the cervix Rumpf proceeded by 
the following plan: He ligated the broad ligament above, opened 
up the parametrial connective tissue, and proceeded to expose 
each ureter in its entire course from the psoas muscle to the 
bladder; thereby the uterine arteries were severed and ligated, 
and the parametrial tissue could be removed bluntly nearly to 
the uterus without incidental bleeding. Subsequently, the ante- 
rior leaflet of the broad ligament was cut through, the peritoneum 
over the surface of the bladder divided transversely, and the 
latter bluntly separated from the cervix. The parametrial tissue 
beneath the ureter could be still further removed. The vagina 
was separated by means of a Paquelin cautery, after the removal 
of the uterus, was filled with iodoform gauze, and the peritoneum 
was closed over the rest of the broad ligament. Rumpf reports a 
case operated upon in this manner which remained free from 
relapse for over two years. This same procedure has been fol- 
lowed by Clark and Kelly, who introduced fine bougies into the 
ureters to render them perceptible. 

Ries advocates the removal of the lymphatic glands on 
account of their being the source from which redevelopment 
occurs. He operates in the following manner: 

1 . Through the vagina he amputates the portio vaginalis and 
tampons with iodoform gauze. 

2 . Through the abdominal incision from the symphysis to the 
umbilicus he ligates the ovarian artery in the infundibulopelvic 
ligament near the pelvic wall, and splits the peritoneum over 
the common iliac, exposes the vessel by blunt and sharp dissec- 
tion until the bifurcation is exposed, when the ureter is separated 
as far as the bladder. 

3 . The broad ligament is ligated toward the pelvis in sections 
and the part toward the uterus is secured with clamps. The 
bladder is separated bluntly from the surrounding broad ligament 
and the uterine artery tied peripherally. 

4. The collected fat tissue with the glands is removed from 
between the large vessels, the external and internal iliac. 

5. The vagina is opened, the uterus removed, and the vaginal 
canal filled with iodoform gauze, while the peritoneal flaps are 
united with continuous silk suture and the belly cavity com- 
pletely closed. 

When infection is so great as to require so extensive a separa- 
tion, the danger from sepsis and from relapse of the disease is 
so marked as to render the operation of questionable value. 
Werder, of Pittsburg, in order to lessen the danger of wound 



GENITAL TUMORS. 



741 



reinfection, does an abdominal hysterectomy in which he Hgates 
the broad ligaments, pushes off the vagina with the bladder, not 
only from the anterior surface of the uterus, but from the anterior 
portion of the vagina for one-third to one-half its length. The 
tissues are also separated from the vagina posteriorly and later- 
ally, the abdominal wound is closed by a previously introduced 
suture or hooked forceps; the uterus is then drawn through the 
vaginal outlet and the remaining portion of the operation com- 
pleted by the vulva, which saves the wound from contact with 
the infected portion. 




^^*»^J^' 



H.iS. 



Fig. 494. — Ligation of the Anterior Trunk of the Internal IHac. 



In order to control hemorrhas^e in an extensive dissection of 
the pelvic structures, Polk advocated ligation of the anterior 
trunk of the internal iliac artery (Fig, 494). The distribution 
of vessels from these trunks is, however, somewhat irregular, the 
vessel itself is short, and the structures supplied by the posterior 
trunk are so bountifully nourished by anastomotic vessels that in 
two cases I tied the internal iliac vessels, which permitted a 
most extensive dissection free from bleeding. In both these cases 
the involvement of structures was so extensive that the operation 



742 GYNECOLOGY. 

was of doubtful utility. The first patient survived the operation 
and returned home, but soon perished from a relapse ; the second 
case developed tetanus at the end of ten days after the operation, 
from which she died. 

Schroder, after ligation of the infundibulopelvic ligaments 
and the portion of the broad ligaments containing the uterine 
arteries, amputated the fundus at about the level of the internal 
OS. After bleeding vessels had been secured and the stump dis- 
sected out, the vaginal surfaces were united, over which the peri- 
toneal flaps were sutured. The operation is objectionable because 
of the danger of reinfection. Mackenrodt urges not only the 
removal of the glands of the pelvis, but also an extensive re- 
moval of the parametric tissue, since in the latter, metastatic 
nests were most frequently found, which were the chief cause 
of recurrence. In order to accomplish this most effectively, he 
advocates the following procedure : 

1. A large crescentic abdominal incision from one iliac spine 
to the symphysis and upward to the opposite is made, through 
which insertions of the recti muscles are divided without opening 
the peritoneum, and the abdominal muscles are separated from 
the pelvic attachments. 

2. The peritoneum is pushed off to its reflection over the 
anterior wall of the bladder, when it is cut through and pushed 
behind the uterus. 

3. The uterus is drawn out and the ovarian arteries ligated 
in the usual manner. The peritoneum is then sutured behind 
the uterus from the right side of the pelvis across to the left, 
covering the sigmoid flexure, which permits the subsequent steps 
to be extraperitoneal. 

4. The pelvic peritoneum is dissected up as high as the iliac 
vessels,- where the glands are found and removed with fat and 
connective tissue. During this stage the ureters are carefully 
protected. 

5. The bladder and rectum are separated, the entire vagina 
freed . 

6. The broad ligaments and paravaginal tissues dissected out, 
the vagina clamped and divided with cautery below the clamps. 

7. The space between the bladder and the abdominal wall is 
drained through the lower angle of the external wound. The 
divided recti are united by silver wire sutures and the abdominal 
wound closed. Considerable suppuration is usually expected 
between the bladder and the rectum. 

579. Comparative Advantages of the Two Proceedings. — The 
principal danger of the abdominal procedure arises from septic 
infection. The investigations of Menge and others have demon- 
strated the presence of pyogenic germs in the discharges of 



GENITAL TUMORS. 743 

uterine cancer. The much longer duration of the operation, the 
increased exposure to infection, and the lessened powers of resist- 
ance favor its development. In the vaginal procedure the peri- 
toneum is less exposed to infection, and the operation can proceed 
without any, or with scarcely any, soiling of the peritoneal cavity. 
In our present methods of procedure the operation is more expe- 
ditious; with the separation of the bladder from the cervix of 
the broad ligament, the uterine artery can be ligated without 
danger to the ureter. 

The Freund operation presents greater oversight of the opera- 
tive field than is afforded by any other method. 

The claim for the abdominal procedure, that it permits the 
extirpation of the lymphatic glands, is of but little significance 
when we remember that the glands are rarely involved until very 
late in the disease; and when the disease has extended to the 
lymphatic glands of the pelvis, the operation is but little better 
than a mutilation, for it will scarcely have any influence upon 
the subsequent progress of the disease. 

Notwithstanding the vaginal operation can be done much 
more expeditiously and with less danger to the patient, with less 
discomfort during the convalescence, it can not be denied that 
in cancer of the uterus where the disease is confined to that 
organ, the abdominal operation should be preferred. This prefer- 
ence is granted it, not because it permits us to extirpate the 
lymphatic glands, — for I believe that no operator is sufficiently 
skilled to make sure that all the lymphatic glands are removed, 
and even if they were, the extensive lymphatic system would 
still afford opportunities for the retention of infection, — but 
because it enables the operator with greater safety to remove 
the parametrial tissue. The large number of cases in which 
vaginal hysterectomy has resulted favorably, the fact that w^here 
recurrence takes place, it is in the cicatrix, in the vaginal wall, 
or in the parametric tissue, leads me to believe that the assertion 
regarding the infrequency or lateness of lymphatic gland infection 
is correct, and that where the disease has resulted in the involve- 
ment of the glands no operation affords much hope of cure. 
In cases in which it is evident that the disease has extended 
outside the uterus and the operation is done for its palliative 
effect, removing only the infected tissue, the vaginal operation 
may be preferred, where the vagina is large and roomy, and 
the uterus not unduly large. 

A narrow contracted vagina, a large or fixed uterus, extensive 
involvement and destruction of the cervical walls, which afford 
no firm tissue to be seized, and more or less fixation of the uterus 
from inflammatory lesions, render the vaginal procedure very 
difficult. Complications of the diseased uterus with abdominal 



744 GYNECOLOGY. 

growths, such as myoma, ovarian tumors, and extra -uterine 
pregnancy, should be attacked through the abdomen. When we 
come to the duration of after-resuhs, the advantage seems to 
favor the abdominal procedure. 

Injuries of the ureters occur less frequently by the abdominal 
route, but the operator in all cases of extensive involvement of 
the parametrium should ascertain the position of the ureter by 
following it down from above before blindly applying a ligature. 
Through neglect of this precaution I have twice ligated a ureter. 
If the ureter is unavoidably or accidentally injured, an attempt 
may be made to unite it by suture, as was done by von Tauffer 
and Westermark, or the ureter may be implanted in the bladder. 

In extensive parametrial involvement, where the infiltrate 
surrounds the uterus, I have in three cases cut through the 
ureter, dissected out the involved structure to the pelvic wall, 
and reinserted the ureter into the bladder at a higher level. In 
all of these patients the ureter was distended to the size of a 
finger as a result of compression from the infiltrate. All recovered 
from the operation, but two succumbed some months later to 
recurrence of the disease, and in the third patient operated upon, 
three months since, the disease has recurred. Ktistner, when 
unable to accomplish a vesical transplantation, formed a vesico- 
vaginal fistula; then performs a colpocleisis in preference to a 
nephrectomy. 

580. The Sacral Method.— Kraske, in 1885, introduced an 
operative procedure, under the title of the sacral method, for 
the purpose of extirpating the upper part of the rectum for 
carcinoma. It consisted in resecting the rectum after the re- 
moval of the coccyx and a portion of the sacrum. Hochenegg, 
in 1888, after a series of brilliant successes, adapted the opera- 
tion to the treatment of some of the disorders of the female 
sexual organs, and the following year reported the application 
of the method to the removal of the uterus. The operation was 
performed as follows: The patient was placed in the Sims posi- 
tion, with the pelvis slightly elevated, an incision was made 
from two to three centimeters above the right sacro-iliac synchon- 
drosis to within one centimeter of the left side of the anus. 
After cutting through the skin and fascia, the under part of 
the sacrum and the entire coccyx were exposed. Now follows 
the bone operation. If the coccyx is large and broad, its re- 
moval is sufficient; otherwise, a portion of the left sacral wing 
is also resected. If a part of the sacrum is to be removed, we 
cut through the sacrosciatic ligaments, and with a rongeur 
cut away the left side of the lower two segments of the sacrum. 
The prevertebral fascia is split the entire length of the wound; 
the now free-lying rectum is bluntly separated on the left side 



GENITAL TUMORS. 



'45 



and displaced to the right. Later experience demonstrated 
the advisabihty of opening upon that side of the rectum on 
which the parametrium was most infiltrated. The rectum 
is shoved aside and Douglas' space opened by a transverse 
incision, which is recognized as the hardest part of the opera- 
tion. One or two fingers are introduced into the opening, 
the uterus and its appendages are explored, and the practic- 
abilitv of their removal is determined. 




Fig. 495. — -Skin Incision for Sacral Resection. 



In removal of the uterus it is seized and drawn through the 
incision of Douglas' space into a position of strong retroflexion. 
The broad ligaments upon both sides are cut between double 
ligatures; when the uterus becomes so movable that it can 
be further drawn down, its anterior surface is inspected. The 
peritoneum above the vesico-uterine reflexion is cut trans- 
versely, and, together with the bladder, pushed downward. 
The uterine arteries are generally ligated under the eye, and 



746 



GYNECOLOGY. 



the ureters easily pushed aside, although they have been in- 
jured. After the separation of the lateral appendages the organ 
remains in union only with the vagina. A transverse incision 
through the peritoneum in front of the uterus is made, which 
is separated and sewed to the peritoneum of the anterior wall 
of the rectum. The vagina is closed in two stages. Iodoform 
gauze is packed about the remaining portion of the wound 
and brought out at the center of the posterior wound, both 




Fig. 496. — Sacrum Resected; Rectum Exposed. 

ends of which have been closed. This operation was extended 
by Herzfeld, who found that, in the majority of cases, only 
the removal of the coccyx was required. He penetrated the 
right side of the rectum, for the reason that the vagina is situated 
more to the right, is more accessible, and there is less inter- 
ference with the rectum. The transverse opening is made 
in Douglas' space, the right and left broad ligaments are tied 



I 



GENITAL TUMORS. 



747 



and cut, after which follows a complete closure of the perito- 
neum before further extirpation. There is no possibility of 
soiling the peritoneal cavity by contact with cancer. The 
rectal peritoneal surface is sewed to that of the bladder and 
the stumps are fastened in the wound laterally, making them 
extraperitoneal. Hegar cut transversely in the anterior uterine 
wall above the bladder fundus, and shoved back the bladder 
and ureters. The remaining removal of the uterus is similar 




Fig. 497. — Rectum Pushed Aside; Uterus Exposed. 



to that described in Hochenegg's and Herzfeld's operation. 
Schede protests earnestly against sacrificing the sacrum. In 
a large series of operations he never found it necessary to re- 
move enough of the sacrum to involve the lower sacral foramen 
and its nerve. He designates the removal of the lower two 
sacral nerves a crime, as the destruction of these nerves para- 
lyzes the detrusor vesica uterini and causes a very severe in- 



748 GYNECOLOGY. 

flammation of the bladder, which increases the distress and 
peril of the patient. Zuckerkandl introduced a still more 
conservative method, in which there was no bone resection. 
Skin section was from the left side of the tuberosity of the 
ilium until midway between the end of the coccyx and the 
anus. At the sacral margin it formed a bow bent hard to the 
right. The gluteus maximus muscle, the sacro-iliac and sacro- 
sciatic ligaments, the musculus coccygeus, and part of the 
levator ani muscle were cut through at the margin of the sacrum 
and coccyx. The rectum is set free and the operation pro- 
ceeded with as previously described. 

Wolffler places the skin section to the right of the sacrum, 
over the somewhat narrowed part at the union of the coccyx 
and sacrum; the section forms an easy curve, with its concavity 
to the right, and ends near the rectum, in the neighborhood 
of the vulvar commissure. The gluteus maximus and the 
levator ani are cut near the rectum, and the deeper structures 
become accessible. Zuckerkandl designated his and Wolffler 's 
methods as parasacral section. These operations are more 
bloody, because the sacral, the median, and the inferior hemor- 
rhoidal arteries, and the pudendal artery and vein are in the 
range of the incision. Hegar made an osteoplastic resection 
of the sacrum and coccyx. A V-like incision, with the arms 
beginning one centimeter beneath each inferior posterior iliac 
spine, converged to the point of the coccyx. After separation 
of the soft parts and bands near the sacral margin the rectum 
was bluntly separated from the anterior sacral surface, a chain- 
saw was introduced between the third and fourth sacral open- 
ings, the sacrum cut transversely through to the posterior 
periosteum, which was retained, and the sacral part turned 
up. After the operation this flap was returned to place and 
secured by sutures. Consolidation usually took place in a 
very short time. In two cases necrosis resulted, and the flap 
had to be removed. After the operation the skin wound was 
closed, with the exception of a small drainage opening, and 
the advantage of the procedure is that the anatomic relations 
are exhibited as before. This osteoplastic resection of the 
sacrum is applicable to the removal of carcinomatous uteri as 
well as retro-uterine tumors. 

Kocher and Heinecke recommend the splitting of the sacrum 
in the middle and the separation of the sides from one another. 
Levy and Schlange, in opposition to Hegar, turned the flap 
toward the anus, while Rydygier made the incision in the soft 
parts on one side, and, after transverse incision, turned the 
sacrum toward the other side. Borelius changed this method 
in the removal of a carcinomatous uterus as follows : He began 



GENITAL TUMORS. 749 

with the skin section in the middle hne, about two centimeters 
above the sacrococcygeal articulation; then, somewhat to the 
left, approached the point of the coccyx forward, through the 
rectosciatic fossa, three to four centimeters from the anal aper- 
ture ; from this point he progressed forward, and again approached 
the middle line until led to the posterior commissure. After 
laying free the left border of the coccyx, the sacrococcygeal 
angle is cut through. The skin section, in its entire length, 
is sufficiently deepened, and the coccyx, together with the anal 
portion, is held to the right; after separation of the rectum we 
can proceed from the posterior vaginal w^all to the extirpation 
of the sexual organs. After the operation the coccyx is replaced 
and fixed with periosteal sutures. 

Various modifications of Hochenegg's procedure for the 
extirpation of the uterus have been introduced; by proceed- 
ing, as Her zf eld suggested, to the right of the rectum, Douglas' 
space will not be missed. In the search for the space— made 
incidentally easy by having an assistant introduce the finger 
into the rectum to indicate the plica trans versalis recti, as the 
cup of Douglas' space ahvays lies at the height of this fold — we 
only need to make the incision to enter the space. The difficulty 
in finding Douglas' space has occasioned the majority of operators 
to renounce the primary opening in the peritoneal cavity en- 
tirely, and to proceed to the extirpation of the uterus by the 
opening from the vagina. 

Incidentally an easy way of accomplishing the uterine 
extirpation would be to follow the proceeding of Czerny, who 
from the vagina cuts about the portio in the same manner and 
separates the structures as in the vaginal method. After com- 
pletion of the operation most operators fill out a somewhat 
fist-sized wound with iodoform gauze and treat it as an open 
wound, with the exception that the wound in the skin is partly 
closed, leaving an opening in the center, through w^hich the 
iodoform gauze is carried out; also, in the osteoplastic resection 
we can not well renounce the use of this drain, and iodoform 
gauze is placed on each side. Steinthal brought the gauze 
out through the vagina, and thus closed the entire posterior 
wound. Zweifel, Schauta, and Wertheim have operated in 
similar manner with favorable results. One objection to this 
operation is the long convalescence, requiring fully six weeks 
for the patient to recover, after which time necrosis of the 
bone may cause fistulous openings, which may continue for 
a much longer period. The osteoplastic resection seems to 
shorten the convalescence. The complete suturing of the 
sacral wound, with drainage through the vagina, is the most 
satisfactory procedure. It can be claimed for the procedure 



750 



GYNECOLOGY. 



that the entire operation can be accomplished more readily 
under the eye, and ligation of the uterine arteries is accomplished 
separately, and not by mass ligature. Injuries of the ureters 
are also easy to avoid. Such injuries, however, do occur. 

The operation may be found advisable in cases in which 
there is reason to suppose that the ureter is embedded in in- 
filtration. In one case Schede resected a piece of the bladder 




\ 



Fig. 498. — Patient from Whom Uterus, Ovaries, Posterior Wall of Vagina, 
Perineum, and Five Inches of the Rectum Have Been Removed. 

A. Artificial anus. B. Anterior wall of vagina. C. Vulva. 

three centimeters long, together with a long piece of the ureter. 
Von Winckel objects to the operation on the ground that he 
could not see the ureters. Hochenegg reported ninety-eight, 
with eighteen fatal cases — eight times sepsis or pelvic phlegmon. 
The loss of blood is much greater than in the vaginal opera- 
tion. In the course of the after-treatment life may be endan- 
gered by bursting of the peritoneal wound. Hochenegg points 



GENITAL TUMORS. 751 

out that, by reason of the sacral method, a large series of cases 
are reported of carcinomata of the bladder; the ureter and 
parametrium have become more or less involved and in- 
creased the technical difficulties that complicate the opera- 
tion. I have removed the uterus, ovaries, and tubes by sacral 
resection in one case without injuring the rectum, and in two 
cases with resection of the rectum. All these cases recovered. 
In one of the latter the operation consisted in the removal 
of five inches of the rectum, the uterus, ovaries, and tubes, 
the posterior wall of the vagina, and the perineum. The rectum 
was stitched to the skin over the sacrum and to the anterior 
wall of the vagina. This operation was performed for epithe- 
lioma involving the rectum, extending to the perineal margin 
around the anus and in the parametrial tissue behind the uterus. 
The patient had previously undergone a Maydl colostomy. 
After the recovery of the posterior wound an incision was made 
around the artificial anus and the two ends of the bowel were 
raised and reunited, after which all fecal discharges took place 
through the sacral anus. Thirteen months after the opera- 
tion the patient returned to her home in Ireland, since which 
time no knowledge has been obtained of her progress. 

581. The Perineal Method. — Zuckerkandl, in the year 1889, 
presented a method for extirpation of the uterus by an opening 
between the vagina and rectum. With the patient in the lith- 
otomy position, the intestine w^as raised toward the sacrum with 
a / \ -shaped flap incision, whose nearly seven centimeters 
long transverse portion lies in the half oval line in front of the 
rectum, and whose angles upon each side extend to the ischial 
tuberosities. After separation of the skin and superficial fascia, 
and separation of the skin flaps from the under layer, the pro- 
jecting bundle of the external sphincter, which penetrates the 
labial commissure, is separated and the lower part of the vagina 
loosened from the rectum. The remaining part of the septum 
is bluntly dissected until Douglas' fold is reached, when the 
vagina is opened transversely, the uterus drawn out from be- 
hind, and its extirpation occurs as readily as in the sacral method. 
The peritoneum is closed, and, after removal of the uterus, 
the ligament stumps can be buried in the peritoneal cavity or 
placed by sutures extraperitoneally, as in the vaginal method. 
Frommel seems to be the only one who has found this operation 
practicable. He holds it advantageous to cut about the vagina, 
as in the vaginal method, push back the bladder, pack the 
vagina with iodoform gauze, and then perform the perineal 
operation. The operation is quite bloody, as the numerous 
venous plexuses between the vagina and rectum are opened. 
The operation seems an unnecessary interference with the 



752 GYNECOLOGY. 

pelvic floor, as the same increased room will be secured by 
enlarging the vagina and the danger from infection must neces- 
sarily be very greatly increased. 

582. The Mortality of Abdominal and Vaginal Operations.— 
The mortality of operations has been greatly decreased with 
the improved operative methods and more careful technic. 
Pryor cites ninety-eight abdominal hysterectomies for cancer 
associated with removal of the lymphatic glands, with a mor- 
tality of 1 1.2 per cent. The advance in the results of vaginal 
work is shown by comparison of the operations of Czerny, 
which, in 1882, showed 32 per cent, mortality, with Wisselinck's 
collection in 1897, of seven hundred cases with a mortality of 
8 per cent. Under especial operations the success to which 
the work can be carried is evidenced by the reports of Olshausen 
and Fehling, the former of whom had but one death in a hundred 
cases, and the latter two. The successes of the operator will 
depend somewhat upon the class of cases in which he operates. 
If he is inclined to operate in desperate cases, the mortality 
will necessarily be increased. The number of cases coming 
under observation early, and favorable for operation, are quite 
small. This is evidenced in the Berlin clinic: with 402 car- 
cinoma cases, only St, were favorable for operation. 

583. Duration of Recovery. — In the earlier operative work, 
it was considered that if a patient survived the operation two 
or three years without recurrence, she might be pronounced 
cured, but further experience has demonstrated that recurrence 
may take place up to the fifth year. After this lapse of time 
the probability of permanent recovery is very great. There are 
occasional cases in which recurrence after partial operation has 
been discovered as late as six, seven, or eight years. It would 
be a question in these cases, however, whether it might not be 
considered a condition similar to that which would take place 
in a woman whose susceptibility to malignant degeneration was 
great, and that the irritation produced in scar tissue would 
favor such development and should be considered a primary, 
rather than a secondary, condition. Frommel, in his investiga- 
tions, has never seen recurrence follow after four years. In 
one hundred and eighty-eight cases of cancer of the neck and 
twenty-six cases of cancer of the body reported by Fritsch he 
saw sixty-five free of recurrence at the end of one year, or 58.5 
per cent, of the cases in the neck and 69.2 per cent, of those in 
the body. At the end of two years Olshausen saw one hundred 
and forty-one, or 44.7 per cent., of the neck, and sixteen, or 
81.2 per cent., of the body free from recurrence; at the end of 
three years he reported one hundred and twelve, or 37.5 per 
cent., of the neck, and thirteen, or 69.2 per cent., of the body. 



GENITAL TUMORS. 753 

At the end of four years he found free from recurrence of cancer 
of the neck eighty-eight, or 29.5 per cent.; of the body, eleven, 
or 63.6 per cent. From this collection it is rendered evident 
that in the first and second years after operation the great ma- 
jority of recurrences appear, and then more and more the num- 
ber falls off. The duration of life following an operation largely 
depends upon the stage of advancement of the disease. Leopold 
is quoted by Williams as having recorded a recurrence of 23.7 
per cent, in early cases as contrasted with 66 per cent, in a more 
advanced stage. 

The final results of individual operators, however, are so 
very different that it is impossible in general to draw valuable 
conclusions from them. Thus, Kaltenbach, with his brilliant 
primary operative results, evidently extends the indications 
for the operation quite far, and subjects all cases to it in which 
it seems technically possible. It is quite readily understood 
that in such a number of cases there must be a few in whom 
the new formation has advanced proportionately far, and that 
relapse is not surprising. Leopold, on the other hand, drew 
the indications very narrowly. The investigation of statistics 
demonstrates that the vaginal operation has given excellent 
primary results, but, on the other hand, it shows that, of all 
the radical operations to which patients are submitted, after 
a year in one-half recurrence has followed, and that it recurs 
in the second year in a still considerable percentage. The 
gravity of the disease can be still further appreciated when 
we realize that only a small percentage of the cases which come 
under the observation of the g^mecologist are in a condition 
to permit of radical operation. 

584. Recurrence.— Those cases subjected to radical opera- 
tion when the parametrium is without doubt extensively in- 
filtrated are not only immediately followed by recurrence of 
cancer, but a fatal termination is also very rapid. Tannen 
has proved that the duration of life in such recurrence of the 
disease is briefer than it would have been had the disease been 
let alone, for duration of life of eight and nine months for 
patients in whom the disease thus recurs is less than would 
be secured by such palliative treatment as partial resection or 
energetic cauterization of the diseased area. Sanger and Thorn 
have shown that by the latter the duration of life is lengthened. 
Surgeons, from their experience in mammary cancer, are in- 
clined to combat these views, but statistics do not support 
them. As contraindications, then, against total extirpation 
are to be considered great enlargement of the uterus and ex- 
tensive adhesions, especially with intestine. Those uteri should 
be excluded from vaginal operation which can not be removed. 

48 



754 GYNECOLOGY. 

through the vagina without morcellation. To this class belong 
those carcinoma which are complicated with myomata. Preg- 
nant and puerperal uteri are proportionately easy to remove 
by the vagina, in spite of their enlargement, as has been demon- 
strated by Olshausen, Hofmeier, and others, and the compara- 
tive narrowing of the vagina observed in the nullipara and in 
old women exhibits no contraindications to the vaginal opera- 
tion. 

The primary operations are so satisfactory that we could 
scarcely wish them otherwise. Olshausen's one hundred total 
extirpations with but one death, when some of the patients 
were already pyemic, are positively brilliant results. Winter 
describes three forms of recurrence: (i) Local or recurrence 
in the wound — a return of the cancer of its primary kind in 
the compass of the field of operation; (2) lymph-gland recur- 
rence, and return of the tumor in any lymph-gland of the body; 
(3) metastatic recurrence. Dissemination by the blood-vessels 
leads to the development of the tumor in the more internal 
organs. The first is produced either by portions of carcino- 
matous growth which have been overlooked in the operation 
or fragments that have been broken off and found lodgment 
in the folds of the wound. These correspond more or less to 
the neighborhood of the previous operation, which demon- 
strates the correctness of Thiersch's view, confirmed by Heiden- 
hain's -investigation on mammary cancer, that the carcinoma 
frequently extended itself far over the lateral or immediate 
limits in small sprigs, and that, after the removal of the new 
formation, the mass is seen to be separated by healthy tissue 
from visible sprigs or microscopic cancer nests that may be 
the source from which the cancer redevelops. 

Our study of the progress of the disease has already illus- 
trated the extension of carcinoma of the vaginal cervix in the 
vault and parametrial connective tissue. Mackenrodt and 
Leopold, in their anatomic investigations of extirpated parts 
of the parametrium, have demonstrated fine, microscopically 
perceptible sprigs situated in remote parts of the parametrium, 
and it is quite possible that such fine sprigs may be found out- 
side of the incision as well. It is, consequently, difficult to 
be certain whether wound relapse occurs from sprigs of cancer 
growth in the parametrium or from small masses which have 
been broken off from the diseased tissue and been implanted 
upon the new wound. Most generally the patient gains in 
body-weight and improves in appearance after the operation, 
but individual cases will be found to exhibit pain in the depth 
of the pelvis at an early period, which radiates from the lower 
extremities, and frequently becomes very distressing. In 



GENITAL TUMORS. 755 

its further course there is edematous swelHng of the lower ex- 
tremities, not rarely venous thrombosis; in other cases, bleed- 
ing and discharge, which cause the patients to return for in- 
vestigation. 

The diagnosis of carcinoma recurrence is mostly fixed with- 
out difficulty if we make a combined investigation from the 
rectum, with the thumb in the vagina, by which the penetrated 
parametrium can be fixed between the finger-tips. Hemor- 
rhage may sometimes take place in granulations which are 
formed about the ligatures, especially if silk has been used. 
When the appendages have been left, a mass may be felt in 
the vagina that has a soft sensation. The cause of bleeding 
upon an exact examination is recognized as the fimbriated end 
of the tube. The absence of infiltration and the impossibility 
of separating the small tumor masses from a polypus of the 
vagina contraindicate carcinoma. In doubtful cases the tissues 
should be examined with the microscope. Another form of 
recurrence is that of which Winter speaks as infection-relapse, 
in which portions of carcinoma are broken off, come in contact 
with healthy tissue, there lodge, and develop the original dis- 
ease. In a single woman upon whom I operated to remove a 
small uterus through the vagina, the operation was attended 
with considerable difficulty; the fundus uteri was torn open 
in attempting to bring it down, and some jelly-like material 
escaped into the peritoneal cavity, w^hich was thoroughly ir- 
rigated as soon as the operation was completed. Less than 
six months later the patient developed a mass upon the side 
of the pelvis corresponding to that into w^hich this fluid material 
had escaped, and, upon opening the mass, material similar 
to that which had escaped from the uterine cavity was found, 
and the disease progressed and eventuated in the death of the 
patient. 

The second form of recurrence is a lymphatic gland recur- 
rence. The investigations of Poirier and Leopold have demon- 
strated that the lymphatic vessels of the middle and upper 
thirds of the vagina and from the cervix proceeded to the iliac 
glands along the course of the iliac vessels and at the sacro- 
iliac articulation in the angle formed by the separation of the 
external and internal iliac vessels. The lymphatic vessels 
of the uterine body proceed to the upper margin of the broad 
ligament and follow the spermatic artery to the vertebral column, 
where they open into the lower lumbar lymphatic glands, which 
are situated behind the peritoneum in the neighborhood of 
the large vessels. Fortunately, lymph infection occurs late 
in cancer of the uterus, so that lymphatic gland recurrence after 
total extirpation is a rare condition. After chloroform narcosis 



756 GYNECOLOGY. 

the roundish, hard, immovable nodules can be recognized in the 
pelvis. 

The third form is that of metastatic recurrence in which 
the disease is carried to more or less distant organs and pre- 
sents nodules of a histologic structure similar to that of the 
primary cancer. These metastases in uterine carcinoma are 
rare, and exist only in advanced stages. 

585. {B) Inoperable. — The great majority of the cases of 
carcinoma which come under the observation of the physician 
are comprised in the inoperable class. Extirpation of the 
uterus adds but little to a favorable prognosis when the dis- 
ease is so extensive, and as palliative and symptomatic ther- 
apeutic measures are obligatory, this section, therefore, is an 
important one in the treatment. The treatment of this large 
division has not received the consideration given to the oper- 
able class, but its value must not be considered trifling. We 
have to study the means which will afford the patient tem- 
porary relief, diminish her suffering, and occasion, at times, 
a hope of recovery. The great variety of methods employed 
betokens the weakness of our efforts to oppose the ravages of 
the fearful disease. 

The principal indication for treatment in inoperable car- 
cinoma of the uterus is to combat such symptoms, as hemor- 
rhage, discharge, and pain. The hemorrhage indicates that 
the new formation of the disease projects into the capillaries 
and small vessels, the walls of which are formed by the cancer 
cells, so that the most trifling injury or increased blood pres- 
sure results in rupture. The later suppuration results from 
wandering-in of saprophytes, which causes the structure to 
break down. The collection of blood and secretion in the 
vagina affords ready entrance to those germs which cause 
suppuration. They may invade the surface of the less well- 
nourished new formation. Hemorrhage and discharge are not 
always marked symptoms. The disease often makes great prog- 
ress without these severe symptoms being present. They may 
exist only as a severe seropurulent discharge similar to that 
which occurs in senile colpitis, while the odor can be almost 
completely absent. In old women we frequently observe hard, 
scirrhous forms of cervix cancer, which show but trifling in- 
clination to disintegrate; consequently, discharge and hemor- 
rhage are wanting, and pain is caused by the further progress 
of the new formation or is exhibited as the only complaint 
of the patient. In such cases we employ narcotics almost 
exclusively. 

Cases which require an aggressive treatment are those forms 
of portio and cervix cancer which are especially characterized 



GENITAL TUMORS. 757 

by vigorous growth of the new formation. The more rapid 
this growth, the more rapid is its transition, and, therefore, 
the earlier hemorrhage and discharge appear. A most effective 
method of treating such a condition is the removal of the newly 
formed mass. In the more gradual development of the dis- 
ease it progresses deeply; its superficial parts perish slowly, 
often with considerable hemorrhage, loss of fluid as offensive 
discharge, decreased appetite, and therewith weariness. Pal- 
liative operative treatment is especially suitable for the cauli- 
flower form of growth in the portio, unless the vaginal walls 
have been invaded. Results are less promising when, v,dth 
existing ulceration, is associated very severe infiltration of 
the pelvic connective tissue surrounding the cervix. Further, 
when the new formation has already invaded the vagina, the 
knife should not be employed to do more than cut away the 
fungiform growth, because the wall is thin and the infiltration 
zone is often difficult to recognize. The knife is especially 
improper in the more deeply situated cancer of the cervix, for 
which the sharp curet should find most employment. The 
operation should be preceded by a careful examination under 
narcosis, which is often necessary to determine contraindica- 
tions to total extirpation. 

A palliative treatment may be employed in order to spare 
the patient further narcosis. In investigation we especially 
observe whether the new formation projects deeply into Douglas' 
cavity or upon the bladder. In such cases injury to organs 
occurs easily, although injury of the rectum rarely follows. 
Approach of the disease to the bladder is best investigated by 
the introduction of a catheter, by which the bladder is pressed 
against the palpating finger. The extension to Douglas' pouch 
is easily recognized by a digital investigation from the rectum. 
In large carcinomatous collections we strive to ascertain the 
extension of the cancer ends beyond the uterus. If the para- 
metrium is invaded, we must prepare for severe hemorrhage, 
as cureting can easily injure the large branches of the uterine 
artery. 

Cureting is the principal palliative operation for cancer, 
but the treatment should not be confined alone to the use of 
the curet. Such treatment injures previously uninvolved 
tissue, which becomes a favorable soil for the extension of the 
disease, and the subsequent progress is more rapid. Cureting 
should always be followed by an immediate employment of 
the cautery or by the application of some strong caustic agent 
which will destroy a large part of the infiltrated zone and reach 
tissue of a more normal character. The uterus is exposed by 
a speculum and lateral retractors. In preparation for the 



758 GYNECOLOGY. 

employment of the cautery the operator should be prepared 
to protect the vagina and external genitalia with wooden re- 
tractors. To avoid too much absorption of light from the depth 
of the cavity by their dark color, their inner surfaces should 
be coated with a thin layer of quicksilver. In addition are 
needed sharp curets, scissors, forceps, needle-holder and needles, 
the latter for use in case of fistula, though they are seldom 
required. We should also have ice- water for irrigation, and 
sponges or pads or, still better, cotton or gauze pads upon long 
forceps. Although the use of the curet is not painful, it is 
advisable for the patient to be under an anesthetic, as the fear 
of burning would be so great that an effectual application of 
the hot iron could not be made. 

While the patient may not ask the character of the dis- 
ease, her fears cause her to anticipate the worst, and her con- 
fidence in what is being done for her will be dependent upon 
its apparent gravity, and the abatement of the symptoms 
which follows the procedure permits her to secure new courage. 
It is well that she should be assured that we do not expect 
to remove completely the discharge, and that subsequent treat- 
ment may be necessary. She is thus saved from utter despair 
upon the return of the discharge. 

The procedure is as follows: The patient, narcotized, is 
placed upon an operating table and the parts are cleansed 
as thoroughly as the condition will permit; the new formation 
is exposed with retractors and as much as possible of the tissue 
is scraped away with a sharp curet, reaching the firm infiltra- 
tion zone. In the softer parts of the cancer the hemorrhage 
is considerable, but becomes less as the infiltration zone is 
reached, because there the vessels still retain their contractile 
power. To limit the bleeding, then, it is important to pro- 
ceed rapidly with the curet. As we proceed, the scraped masses 
are removed by irrigation with ice-water, or, probably equally 
effectively, with water at a temperature of 120° F. The irri- 
gation enables us the better to inspect the operative field. The 
finger must be employed occasionally to judge of the progress 
and of the amount of resistance, especially of thin points, par- 
ticularly in the posterior vaginal vault and over the bladder, 
to assure ourselves that perforation will not occur, and that 
the new formation has been sufficiently removed. A smaller 
curet can be employed to remove further tufts in the uterine 
cavity. Shreds and ragged masses which elude the curet are 
seized with forceps and cut away with scissors, and the bleed- 
ing is controlled by firm pressure with gauze pledgets. A 
crater-like cavity is formed, which frequently can project into 
the parame trial tissue, which is further cleansed, and from 



GENITAL TUMORS. 759 

which hemorrhage is arrested by the use of the thermocautery. 
It has been advised that the thermocautery be followed by 
coating the vaginal walls with vaselin, impregnating the diseased 
structure with alcohol and igniting it, allowing it to burn for 
one-half minute to a minute and a half. In the most favor- 
able cases cicatrization is produced. With cicatrization the 
cavity shrinks, and is much diminished. The action of the 
Paquelin thermocautery must be prolonged to be most effective. 
It must be frequently removed, because blood and shreds of 
tissue rapidly coat it. The removal is also done to permit the 
tissues to cool, that undue scorching may not occur at undesir- 
able points. When the hemorrhage is quite profuse, it is im- 
portant to bring the entire cavity at once in contact with the 
cautery. After the hemorrhage is incidentally controlled, 
we see, here and there, blood trickling and oozing from small 
points, which must be resubjected to the cautery until the 
cavity is lined by a thick, dry eschar. Especial care must be 
exercised toward the vaginal margin, for bleeding will con- 
tinue there the longest. 

To secure a deep, dry eschar, we use irrigation with ice- 
water at intervals only in the early part of the treatment, and 
later withdraw and cool the retractors, or retain them in the 
vagina and cool with a pad wet with ice- water. If these pre- 
cautions are omitted, the vagina becomes severely burned in 
prolonged operations. With the wooden retractors the danger 
of burning is lessened, but the long employment of the cautery 
will require an occasional cooling of the cavity. The procedure 
concluded, the cavity should be packed with iodoform gauze. 
Fritsch advises that the tampon be preceded by a teaspoonful 
of a powder containing equal parts of boric acid and tannin. 

In properly selected and carefully managed cases the danger 
of the procedure is slight, and it can be accomplished with- 
out injury to the bladder or the peritoneum. Injuries to the 
latter are usually not serious. The hemorrhage may be con- 
siderable, though it is usually controlled without difficulty 
by the prolonged use of the cautery. A ligature is rarely re- 
quired, for the cautery is competent to control even arterial 
bleeding. In the rare cases of inoperable cancer of the uterine 
body great prudence must be exercised to prevent the cautery 
from perforating the thin walls. The finger can generally enter 
the cavity, by which the weak places can be recognized and 
undue pressure against them avoided. The procedure is usually 
borne with but little discomfort. The patient will scarcely 
complain, unless we have unfortunately made an eschar upon 
the external genitalia, which is very painful and soon becomes 
edematous. 



760 GYNECOLOGY. 

After the procedure is completed the vulva should be covered 
with vaselin, and, in the most trifling external burning, a 
pad should be applied, which is frequently wet with lead- water 
and laudanum, or a carbolic acid solution should be applied 
to the external genitalia. Slight elevation of temperature is 
generally noticed after such operations, but they exert no marked 
influence upon the general condition, and the temperature 
subsides in a few days. 

Parametritis and septic processes are rarely observed. The 
tampon should remain five or six days. The eschar will be 
found to have partly separated under trifling suppuration, 
and the cavity will be more or less diminished. After with- 
drawal of the tampon the loose-lying tissues are carefully re- 
moved. The exercise of force must be avoided, because it 
causes hemorrhage. The cavity is sponged, and we await the 
complete separation of the slough. Our treatment after the 
removal of the eschar is directed to the securing of cicatrization. 
Olshausen lauds for this purpose tincture of iodin. He employs 
the stronger solution: 

R . Iodin, pur., i part 

Rectified spirits 8 parts. 

It is applied by a saturated pledget of cotton, which is pressed 
lightly against the cervix. The superfluous portion flows 
back into the bowl of the speculum, from which it may be used 
over and over. The alcohol is an excellent antiseptic. 

The patient should be advised to wear a napkin after the 
application to protect the clothing. The applications are made 
every two or three days until the cavity contracts and becomes 
clean. In favorable cases a watery discharge, sometimes tinged 
with blood, follows, which has entirely lost its offensive odor 
and is so slight that the patient considers herself cured. Torg- 
gler tampons the vagina with iodoform gauze saturated with 
peroxid of hydrogen and permits it to remain for three or four 
days. The surface is scraped with the sharp curet, subjected 
to the thermocautery, and covered for a few minutes with 
cotton soaked with a 40 per cent, solution of formaldehyde. 
Six to ten days later a slough is thrown off, which leaves a dry 
wound. 

Caustics. — Sims followed the use of the curet by an applica- 
tion of zinc chlorid solution. Hemorrhage was controlled by 
pledgets wet with a solution of persulphate of iron, which were 
removed and followed by tampons wet with the zinc solution. 
Van de Warker used a 50 per cent, solution of the chlorid of 
zinc. After the use of the curet small pledgets, squeezed from 
a 50 per cent, solution of zinc chlorid, are placed against the 



GENITAL TUMORS. 761 

diseased surfaces. The healthy tissues are previously pro- 
tected from injury by an ointment of bicarbonate of soda in 
vaselin. These medicated pledgets are so placed as to come 
in contact with the entire diseased surface; over them a piece 
of dry absorbent cotton or gauze is laid, after which the vagina 
is filled with a wad of cotton wet with a saturated solution of 
bicarbonate of soda. 

The carbonate causes a decomposition of the zinc salt, which 
renders it nonirritating to the tissues. The nurse can press the 
superfluous agent out of the pledgets without injury to her fingers 
by first anointing them with vaselin. Without the precaution 
above directed, the vagina, and especially the introitus, would 
be badly burned ; indeed, in spite of every precaution the vagina 
is frequently seriously injured. Where the wall is thin, as over 
the bladder, the weaker solution (5vj to f^j) employed by Sims 
should be substituted. Sims left the tampons undisturbed for 
four or five days, unless earlier removal w^as indicated by eleva- 
tion of temperature. He ascribed to the agent no especial infiu- 
ence upon the cancer beyond its active destructive eft'ect, but 
Van de Warker believes the drug to have a special affinity for 
the cancer tissue, selecting it and leaving the healthy tissue. The 
microscopic investigations of Ehler upon this subject, however, 
demonstrate the contrary — that the cancerous tissue is only super- 
ficially affected, while necrosis of the healthy tissue extends to a 
considerable depth. Frankel employs the zinc salt, but previ- 
ously scorches the surface with the thermocautery. He leaves 
the pledgets in contact with the aftected surface for twenty-four 
hours. Great care must be exercised in the cases for which this 
treatment is employed. Should the bladder or posterior vaginal 
wall be infiltrated, or if these parts are insufficiently protected, 
fistulce may form, which greatly aggravate the subsequent con- 
dition of the patient. A slough resulting from the application 
may open the bladder, rectum, or peritoneal cavity. During or 
following the separation of the slough, a hemorrhage so severe 
as to cause a fatal result may readily occur. When the slough 
has separated exuberant granulations develop, and later strong 
cicatricial contraction and shrinking, w^hich Fritsch indicated as 
the cause of extraordinarily severe pain, which is aggravated by 
the increased infiltration above the scar tissue. 

Ricard relates the history of a patient in whom hematometra 
and hematosalpinx followed the introduction of zinc chlorid 
pencils into the uterus. The scar tissue w^as so dense that the 
collection could not be reached per vaginam, and the woman 
perished from hemorrhage after laparotomy. The cervix and the 
greater part of the uterus had degenerated in cancer. I\Iany 
patients in whom this treatment has been employed have been 



762 GYNECOLOGY. 

SO much improved as fully to justify its practice in similar cases, 
but strong solutions and the paste should be absolutely in- 
terdicted. 

Fraipont advocates the use of liquor ferri sesqui chloridi, from 
which he obtained excellent results. This agent has a superficial 
action upon the surfaces to which it is applied, and forms a 
slough, following the discharge of which hemorrhage is likely to 
recur. The bleeding following the curetment can only be incom- 
pletely controlled by pressure with an iron solution. A better 
application is a tampon of iron chlorid. Cotton is saturated with 
this substance and packed against the surface. These pledgets of 
cotton form hard lumps, which are difficult to move, and are 
only slowly separated under strong suppuration or discharge. An 
early attempt at their removal is attended with severe pain and 
hemorrhage. 

Leopold advocates the use of a concentrated carbolic acid 
treatment which he continues from one to two months. After 
radical scraping and scorching with Paquelin's cautery, he supple- 
mented this with quarterly scraping and the use of the cautery 
by plunging it into the new growths so that the tissue is rapidly 
scorched. Chrobak used, after cureting, repeated cauterization 
with nitric acid. Out of sixty-five cases so treated, he attained 
good duration results. In one of these cases, after radical slough- 
ing of the carcinoma of the cervix three years and nine months 
later, because of the strong scar tissue, there had formed a hema- 
tometra, which was emptied twice. In other cases after repeated 
cureting and cauterization, strong scar formation, was seen at the 
end of three years without recurrence. The third patient still 
lived five years after operation, free from recurrence. 

M. Guinard, in 1896, and Etheridge, in 1898, advocated the 
employment of calcium carbide. In the treatment of inoperable 
uterine cancer a piece of calcium carbide the size of a small 
nut is introduced into the vagina, and iodoform gauze is quickly 
packed about it. It forms acetylene. Three days later the 
dressings are removed and the vagina well washed, the remains 
of the calcium oxid are brought away, the parts are dried, and 
a new application is made. The vegetations rapidly disappear, 
and there remains only a smooth gray surface, free from moisture. 
Etheridge claimed that after a few treatments the edges of the 
cavity began to draw in, and the area of the crater was dimin- 
ished. Its entire appearance impressed one with the idea that it 
had taken on an entirely healthy character. The cavity contracts 
until it is entirely obliterated, and puckers the vault of the 
vagina. This treatment does not seem to have stood the test of 
time, and is now scarcely considered. Goodell advocated in 
inoperable cancer the use of applications of powdered pepsin 



GENITAL TUMORS. 763 

and salicylic acid — pepsin to digest and eat off the diseased 
tissues, salicylic acid to prevent decomposition. Cucca and Un- 
gara advocate tampons wet with : 

R . Methyl-blue, gr. xc 

Alcohol (,95 per cent.), 

Glycerin, aa f,^iij 

Water, f I vij . M. 

Apply to the diseased surface. 

It arrests hemorrhage, aborts discharge, and prolongs life. 

Parenchymatous Injections.^VsiTions agents have been em- 
ployed as injections into the structiire of the cancer Avith a view 
to moderating its course or destroying it. Thiersch used nitrate 
of silver; Schramm, chlorid of sodium and sublimate. Mosetig- 
Moorhof and Stilling employed pyoktanin. Schultze has lately 
used injections of absolute alcohol in a large series of cases. Bern- 
hardt employed a 6 per cent, solution of salicylic acid in 60 per 
cent, alcohol. Vulliet, independently of Schultze, has practised 
the treatment with absolute alcohol. Under this treatment the 
bleeding and discharge were trifling or ceased entirely. After ten 
or fifteen injections the evil smell of the discharge disappeared 
and the pain ceased. Treatment, in the beginning, should occur 
at intervals of a few days. During the intervals the vagina may 
be tamponed with iodoform gauze. In the course of weeks or 
months the ulcer heals and the infiltrate disappears. Schultze 
suggests that when the injection is in the neighborhood of the peri- 
toneum, the after-treatment is painful. Schramm found the in- 
jections painful and without special influence. The treatment 
has to be continued over weeks and months — a requirement that 
we are able to carry out only in rare cases. Without question, 
better results Avill be obtained by the use of the curet and the 
thermocautery. 

A. Martin, in inoperable cases, advocates suturing the wound 
surface occasioned by the curetment. The carcinomatous masses 
are removed with the sharp spoon and the parametrium is ligated ; 
then, drawing down the uterine stump, strong curved needles are 
passed under the entire wound surface to the border of the neck 
or to the mucous membrane, and the thread is so secured that it 
brings together the wound surfaces created by the curetment. In 
a very extensive wound the entire pelvic body is protected by a 
mattress suture, when the mobility of the stump is so limited that 
it is impossible to accomplish the partial sewing of the wound 
surface. The vagina is so sutured in the depth of the crater that 
a continuous series of firm sutures come to lie about the opening. 
The operation, however, is impracticable, because frequently we 
have to clean out extensive cavities with strong infiltrated walls. 
The advantages offered by the method are that hemorrhage is 



764 GYNECOLOGY. 

securely controlled and that after-hemorrhages do not appear. 
The patient is spared the suppuration which follows the caustic, 
and it forms a firm scar. Houzel and Chrobak have seen good 
results from suturing. The method, however, is applicable only 
to a limited number of cases, and frequently offers great technical 
difficulties. Sutures will often cut through the carcinomatous 
tissue ; sometimes the wound surfaces break apart, and suppura- 
tion again follows. The reported good results are less from the 
suture of the wound surface than from the union with the para- 
metrium. 

A class of cases will be found in which the disease is such 
that no palliative operation will afford relief. We must still 
endeavor to make the patient comfortable and to relieve the dis- 
tressing symptoms. These are hemorrhage and profuse offensive 
discharge. The latter becomes so disgusting as to be distressing 
to the patient and to those about her. Local treatment is de- 
manded. Syringing and tamponade with wet or dry dressings 
come under consideration. The control of hemorrhage is accom- 
plished more effectually by the tamponade than by syringing with 
astringents. Kehrer employed the tampon with cotton gauze 
saturated in an 8 to lo per cent, solution of acetic alum. Iodo- 
form gauze also exercises a good influence upon the smell of the 
discharge, but through a long employment the odor of the iodo- 
form becomes persistent and annoying. 

The dry treatment, introduced by Sanger and employed by 
Fritsch, often proves beneficial, though it requires medicinal help 
in order to carry it out. It may be employed alternately with 
injections. The dry treatment follows curetment and cauteriza- 
tion. Iodoform is blown into the vagina, which is then firmly 
tamponed with iodoform gauze. Tamponades covered with iodo- 
form may be introduced, and may remain as long as possible. 
This treatment should be repeated once or twice a week for some 
time. It controls hemorrhage, but especially keeps down the 
unpleasant smell of the discharge. The unpleasant odor of the 
iodoform and the existing danger of intoxication have led to the 
substitution of tannin and boric acid and salicylic acid for similar 
purposes. Torggler employed charcoal powder with iodoform, 
which deodorized the mixture; the ulcerated surfaces were rap- 
idly cleaned. Long-continued sitz-baths often have a beneficial 
influence and afford the patient great relief. When penetration 
of the bladder occurs, the patient may keep herself comparatively 
comfortable by wearing a urinal. 

It is important that the patient should be kept out of bed as 
long as her strength will permit. When once she becomes bed- 
ridden, her condition is made worse, and the psychic depression 
is more marked. It requires the greatest cleanliness and most 



GENITAL TUMORS. 765 

continuous care upon the part of the nurse to limit the occur- 
rence of bed-sores, as the continuous and abundant discharge 
keeps the parts wet, and in emaciated persons with feeble powers 
of resistance the skin becomes broken and extensive bed-sores 
follow. In these enfeebled patients it is not to be expected that 
the loss of substance will be recovered, and scarcely that the 
wound surface can be kept clean. By the processes of absorption 
from the wound surface, and the breaking-down cancer, the 
patient soon has regular elevation of temperature, which aggra- 
vates the discharge. It is not worth w^hile giving antipyretics 
for the elevation of temperature in these cases, as they have but 
trifling influence, and soon break down nutritive processes. A 
mixture of salol and aristol has been employed with advantage. 
When the patient is unable to be continuously under medical 
treatment, resort must be had to irrigation. The entire series of 
antiseptic means have been employed; injections of permanga- 
nate of potash, one to two teaspoonfuls of 5 per cent, solution in 
a gallon of water, is one of the best. The drug is cheap, and 
possesses the advantage that the patient is using a substance that 
does not irritate or burn, is completely odorless, and is an excel- 
lent disinfecting fluid. It has the advantage over the phenols 
that the peculiar smell of the latter, mixed with cancer discharge, 
soon annoys the patient. Martin recommended for a deodorizing 
injection a solution of 3 per cent, hydrogen peroxid with i per 
cent, thymol. Various astringent fluids, as pyroligneous acid 
and alum solution, are favored. 

If penetration of the bladder and rectum has already resulted, 
the condition of the patient is comfortless. We may use tampons 
saturated with fatty or oily mixtures, such as bismuth salve or 
carbolized oil. The discharge is thus sometimes held back, but 
the continued irritation of the parts results in an excoriation 
eczema of the external genitalia, which is a new source of torment 
for the unfortunate patient. In such cases the removal of the 
disagreeable odor is no longer possible. In patients suffering 
from edematous external genitalia covered with excoriations and 
ulcers, and from already existing edema in the lower extremities, 
irrigation is very difficult, and is practicable only under increase 
of pain. Covering the lower extremities with a rubber skirt, by 
which the odor is prevented from rising, has been advocated, 
but the moist warmth thus engendered soon renders it unbear- 
able. Fritsch advocates completely covering the vulva and the 
inner surface of the thighs with frequently changed pads wet 
with chlorin water, thus to obscure as much as possible the offen- 
sive odor. 

When the disease is far advanced, neither the greatest clean- 
liness nor the admission of fresh air to the sick-room is sufficient 



766 GYNECOLOGY. 

to drive out this odor, and the patient becomes a source of dis- 
comfort to herself and to those who attend her. Anorexia makes 
itself noticeable early. This is undoubtedly due to the influence 
of the sickening odor upon the appetite. Every form of food 
becomes absolutely repugnant, and we are obliged to confine 
ourselves then to the smallest quantities of liquid nourishment. 
Sometimes these are more readily taken when cold. Patients 
frequently live for a remarkable length of time with scarcely any 
nourishment. The relief occasioned by the removal of the odor 
usually results in the improvement of the appetite. Obstinate 
constipation becomes a marked symptom, which also acts unfa- 
vorably on the appetite. When evacuation occurs, it is so 
extraordinarily painful, because of the hard infiltration in the 
pelvis, that the patients are constrained to avoid defecation in 
order to escape the pain. Large enemata are better than purga- 
tives in such cases. Of course, if a rectal fistula exists, they can 
not be employed. The uncontrollable vomiting which marks the 
advent of a uremic condition is an exceedingly distressing symp- 
tom. Occasionally, the administration of diuretics will relieve 
it. The condition of the urinary secretion should be observed; 
any failure should be an indication to administer diuretics, by 
which the appearance of vomiting can be obviated. 

In the later stages the third distressing symptom is pain, 
which can be avoided only by the free use of narcotics. The only 
hesitation in the administration of narcotics should be to avoid 
their too lavish use early. The patient who becomes accustomed 
to large doses of the narcotics, when she reaches a stage at which 
they are still more seriously needed will have become so inured 
to the drug that it is no longer useful. Early in the disease it is 
better to employ other agents as substitutes. Antipyrin has been 
found effective. In extensive infiltration involving the lateral 
and posterior parts of the pelvis this remedy is useless. Such 
cases are relieved by rectal suppositories containing : 

R . Morphin sulph., gr. | 

Pulv. opii pur., gr. | 

Pulv. belladon., gr. ^ 

Ol. theobrom. , 3 ij . 

Ft. supposit. 

Such a suppository, given at night, relieves the distress, secures 
sleep, and enables us to avoid the larger doses of morphin. An 
additional advantage is that by such a combination we can in- 
crease the dose and give the patient the prescribed daily ration 
which she can use. Codein may be given in pill form. In the 
later stages of the disease only the subcutaneous employment of 
large doses of morphin will afford relief. Fortunately for the 
patient and her relatives, toward the end of the disease the com- 



GENITAL TUMORS. 767 

pression and obstruction of the ureters occasionally cause 
sufficient uremia to obtund the. general sensibility and lessen the 
discomfort. The soporose and comatose conditions are frequent, 
and increase the comfort of the patient. Cumston's proposition 
to relieve the obstruction by establishing a ureteral fistula or 
performing a nephrotomy should receive no consideration. In 
advanced stages Drszewczky claims benefit from an ointment of 
extract of condurango and vaselin. 

586. Pregnancy Complicating Carcinoma. — We have already 
spoken of the occurrence of pregnancy as a complication of car- 
cinoma — a complication which is fraught with the greatest danger 
to two lives. It was stated that the treatment would entirely 
depend upon the progress of the disease. Thus, if the disease 
was inoperable, and there was no possible chance for the mother, 
every effort should be made to prolong the pregnancy to full 
term or to viability of the child, in order that it should have a 
chance for its life; when, however, the disease is operable and 
there is hope for a radical cure of the patient, no consideration 
for the child should operate against the mother's chances. The 
continuation of the pregnancy is doubtful, and it is attended with 
improbability of the child being delivered alive. Danger to the 
mother is very greatly increased, with almost the certainty that 
the progress of the disease will be so rapid that at the termination 
of pregnancy the time for radical treatment will be found to be 
past. Under such circumstances the proper consideration is the 
life of the mother. If the pregnancy has not reached the fourth 
month, we may proceed to the removal of the uterus per vaginam. 
Emptying the uterus reduces its size and renders easier its sub- 
sequent removal through the vagina. In the fourth month the 
operation should be performed through the abdomen. Between 
the fifth and seventh months we may be governed by the condi- 
tion as to whether we wait for viability or proceed to immediate 
operation. If the disease is apparently progressing rapidly, an 
operation should be done immediately, without regard to the 
child. We may resort to an abortion, and then operate through 
the vagina, or the abdomen may be opened. In advanced preg- 
nancy Martin has advocated the supravaginal amputation of the 
uterus and the extirpation of the carcinomatous cervix by the 
vagina. The advantages of this procedure are that the abdomen 
is kept open but a short time, that the hemorrhage can be better 
controlled from below, and that the carcinomatous masses are 
not drawn back through the abdominal cavity. Of six patients 
thus operated upon, one died of septic peritonitis. In the last 
two months of pregnancy we have to consider the treatment 
which has in view the preservation of two lives. Cesarean section 
should be performed, which is followed by a Freund abdominal, 



768 GYNECOLOGY. 

the Zweifel combined, or, finally, the pure vaginal total extir- 
pation. Of these procedures, the abdominal operation seems 
preferable. 

We come next to the consideration of operable carcinoma in 
labor. Here we have the possibility of a spontaneous ending of 
labor through the diseased passages. This may be considered, if 
the disease is still in the early stages. If the carcinomatous infil- 
tration has not involved the entire portio, and a more or less 
large zone of the uterine margin remains free and capable of 
dilating, the ovum may be thus extruded. When the carcino- 
matous masses can not be crushed by the head, they should be 
cut away with scissors or the thermocautery as a preliminary, 
and the child should be delivered by forceps or by version. If 
the ovum is dead, its size may be diminished by perforation or 
by piecemeal operation, whichever will end the labor most effect- 
ively and in the best manner for the mother. Following the 
delivery, we may consider immediate vaginal total extirpation, 
or its delay until the second week of the puerperium. The delay 
in these cases is suggested because of the size of the uterus. The 
advantages of the procedure, however, are that the uterus permits 
itself to be readily drawn down to the vulva, and that the wall 
of the vulva and the vagina have been so distended by the pas- 
sage of the fetus that they do not afford an artificial hindrance. 
Occasionally, the size of the uterus affords difficulty. It can then 
be reduced by splitting it into two parts in the median line, but 
this endangers the reinfection of the wound. 

587. Summary. ^In the discussion of the subject of cancer I 
have endeavored to give a comprehensive view of the methods 
by which the disease can be combated. As such a statement 
must be, however, more or less confusing to the student, it is 
my purpose in this section to briefly present the indications for 
special treatment. The two principal methods of treating 
operable cancer are by the abdominal and vaginal routes. The 
sacral method affords no advantages which render it worthy of 
consideration. When the uterus is large and the disease has 
evidently extended to, if not into, the parametrium and is com- 
plicated with myoma, ovarian tumor, or the later stages of 
pregnancy, or when the vagina is undilated and narrow, ab- 
dominal hysterectomy should be preferred. Vaginal hysterec- 
tomy when carcinoma is limited to a uterus freely movable, not 
too large and accessible through a roomy vagina, has been the 
operation of election. The after-results, however, have demon- 
strated that vaginal hysterectomy, as ordinarily performed, is 
ineffective in that it does not afford opportunity for the removal 
of sufficient tissue to insure against early recurrence. The 
operator should keep two objects in mind in proceeding to per- 



GENITAL TUMORS. 769 

form any operation for carcinoma : ( i ) To insure the removal of 
a diseased organ in a healthy field, which is accomplished where 
possible by the removal of the tipper part of the vagina and 
as much parametrial tissue as safety for the ureters and bladder 
will permit, thus getting beyond the isolated nests, which may 
be situated in the parametrium; (2) the exercise of such pre- 
cautions as will avoid the implantation of cancerous material 
upon the healthy wound. 

In the vaginal operation we have the choice of three methods 
of procedure for the control of hemorrhage. These are the 
employment of pressure forceps or clamps, the electric cautery, 
and the ligature. The clamp procedure has the advantage of 
being more expeditious, enabling us to remove the uterus in 
favorable cases in a very few minutes. It has the disadvantage 
that it produces an increased amount of pain, from the weight 
and dragging of the clamps and the necessity of the patient being 
confined to the dorsal position. The retention of the clamps 
produces a certain amount of necrotic tissue in the peritoneal 
cavity after removal of the clamp, and causes increased danger 
of septic infection. The removal of the clamps, often as late 
as forty-eight hours, is sometimes attended with quite free after- 
bleeding, which may require their reapplication, under very great 
disadvantage, in order to save the life of the patient. In a large 
hospital where there is a convenient electric light plant or con- 
nection with the street current can be made, the electrocautery 
is ideal, otherwise it means the employment of special apparatus, 
which is cumbersome and requires expert skill to manage and 
maintain in order. The ligature method is slower, but the 
hemostasis is more sure and the comfort of the patient is en- 
hanced during convalescence. Catgut is preferable to silk for the 
ligature, because the latter ligature is likely to become infected, 
after which the silk will cause a sinus and a discharge, which 
continues until the ligature is removed, and causes worry and 
distress to the patient, inducing her to believe that the disease 
is returning. 

In an abdominal hysterectomy the method suggested in 
Section 578 is the proper course. The uterine arteries should 
be ligated separately near their origin, the course of the ureters 
observed, and an extensive removal of the parametrium and 
upper part of the vagina made. This procedure, in my judg- 
ment, is more important than the removal of glands. Before 
closing the wound, bleeding vessels are carefully secured. When 
there is much oozing or a large surface has been denuded of 
peritoneum, gauze is carried through the opening into the vagina, 
packed into the cellular tissue upon each side, and the peritoneum 
united over it bv a continuous catgut suture. The abdominal 

49 



770 



GYNECOLOGY. 



cavity is cleansed ; the wound is closed as in ordinary abdominal 
procedures. The gauze packing in these cases may be left in for 
from six to eight days and then removed through the vagina. 

588. Chorio -epithelioma Malignum. — Some fifteen years ago a 
condition was recognized as a form of malignant disease which 
is intimately associated with pregnancy. It has been described 
under the various names of deciduoma malignum, deciduomatous 
sarcoma, sarcoma deciduo cellulare, blastoma, deciduo chorion 
cellulare, syncytium carcinoma, syncytio malignum, the destruc- 
tive bladder mole, destructive placental polyp, and the title of 
our section, chorio -epithelioma malignum. These various desig- 
nations indicate the attempts upon the part of the different 




Fig. 499. — Chorio-epithelioma Malignum. (Section furnished by Drs. C. 

Noble and S. E. Tracy.) 
a, a. Large syncytial cells, h, Blood detritus. 



investigators to name the structural origin of the condition. 
(Fig. 499.) It was formerly supposed to be due to the degenera- 
tive changes resulting from a cyst mole, from which metastases 
were carried by the veins to different points, and growths of the 
similar epithelial structure followed. Later investigations, how- 
ever, have disclosed that the mole is not necessary to its develop- 
ment, although favoring its growth. Later investigators agree 
with Marchand that it arises from the syncytial cells, although 
there is still want of agreement as to whether these cells are 
fetal or maternal. 



GENITAL TUMORS. 771 

Etiology. — The disease occurs during the period of active 
reproductive Hfe and follows an abortion, either intrauterine or 
tubal, a normal labor, and frequently a hydatid mole. It has 
been attributed to want of nourishment in the villi. The condi- 
tion has occurred during pregnancy, as Pick reports a case in 
which a tumor was situated in the posterior wall of the vagina, 
which, upon removal, contained distended chorionic villi with 
proliferated sync37tial cells. 

Symptoms. — In a few days to a few months following the 
termination of a pregnancy a patient suffers from repeated 
bleeding, increasing in severity, the patient becoming markedly 
anemic. There will also be a profuse dirty watery discharge. 
The continued drain, the hemorrhage and discharge, give rise to 
extreme weakness and a cachectic appearance. Curetment of the 
uterus in a condition like this results in the removal of a varying 
quantity of soft, friable material, which looks like placenta and 
bleeds freely. Oftentimes it will contain necrotic tissue, causing 
an extremely offensive odor. Very frequently a metastasis in 
the form of small round masses will be observed on the anterior 
wall of the vagina, which, on being opened, will present tissue 
similar to that removed from the uterus. Similar metastases 
result in the formation of growths in other portions of the body. 
Thus we may find it carried to the lungs, pleura, diaphragm, 
spleen, pericardium, kidney, liver, intestines, and even the brain. 
When the diseased tissue is cureted from the uterus, the patient 
has but temporary relief ; hemorrhages again return, and a second 
curetment will remove tissue similar to that which w^as found 
in the first employment of this instrument. 

Diagnosis. — Diagnosis is easy in the advanced cases, but diffi- 
cult in early stages. It is determined both by clinical observation 
and microscopic investigation. The rapid return of hemorrhage 
after the curetment in which no fetal products are found, the 
foul discharges, the profound anemia, elevation of temperature, 
large uterus, dilated os, soft friable tumor, and the metastasis, 
with the revelations of the microscope, should render the diag- 
nosis positive. The disease so closely resembles both carcinoma 
and sarcoma as to render it difficult to differentiate betAveen 
them. Its structure having no stroma and being disseminated by 
the blood-vessels rather than by the lymphatics makes it closely 
akin to sarcoma. From sarcoma, however, it is differentiated 
by the fact that it is composed largely of epithelial elements. 

Prognosis. — The prognosis is extremely grave. The only hope 
will be in its early recognition and the prompt extirpation of 
the uterus. Marchand reports twenty-eight cases with twenty- 
four deaths. It is one of the most malignant of gro^^^hs, and 
generally recurs in six months, whether operation is done or not. 



772 



GYNECOLOGY. 



Veit reported recovery after metastases had occurred, but this 
is contrary to the general experience. In the extirpation of the 
disease the abdominal operation is preferable, for the reason 
that there is less danger of fragments of the tissue being forced 
into the veins. 

589. Endothelioma Uteri. — A recently recognized form of 
malignant disease which occurs in various tissues of the body 
is known as endothelioma, and has its origin in the endothelial 
lining of the blood- and lymph-vessels and the serous membranes. 
These growths manifest themselves in many ways, according to 
the structures involved and the particular endothelium from 



a - 




Fig. 500. — Endothelioma of the Uterus. 
a, a. Endothehal cells infiltrating lymph-spaces, b. Blood-cells. 

tive-tissue matrix. 



c. Connec- 



which they have originated. The disease may occur in the cer- 
vix, although extremely rare, and is very similar to that of the 
squamous-cell carcinoma, and the diagnosis can only be deter- 
mined by the employment of the microscope. The examination 
of the section of tissue reveals the squamous epithelium intact, 
free from any infolding process projecting into the underlying 
tissue. The growth consists of spaces lined by one or more layers 
of cells, resembling lymph-spaces. Where these spaces are ob- 
literated by masses of proliferative cells, there is a resemblance 
to the squamous nests, but in the latter the outer layer assumes 
a cuboidal or more cylindrical form and the nuclei are more 



GENITAL TUMORS. 773 

vesicular. (Fig. 500.) When the disease involves the body of 
the uterus, it is likely to form a tumor of considerable size, 
and in its course and progress will resemble sarcoma. Metastases 
usually occur through the blood-vessels. In my own experience, 
I have noted that it is very prone to extend upon the peritoneal 
surface and result in the formation of numerous nodules over 
the peritoneum, and even eventuate in intestinal obstruction. 
Unless the latter symptoms occur, the disease is singularly free 
from pain, the patient complaining rather of the progressive 
emaciation and the continuous loss of strength. The prognosis 
is very unfavorable, since the disease progresses by both the 
lymph- and blood-vessels, but more frequently by the latter. 

590. Sarcoma Uteri. — Sarcoma of the uterus can involve 
either the mucous membrane or the wall of the organ, and 
hence is divided into two groups. Clinically it is found either 
in the body or in the cervix, more frequently in the former, 
and this holds true in both its anatomic varieties. Sarcoma of 
the mucous membrane is one and one-half times more frequent 
than the same infection of the wall. It differs from carcinoma 
in that it is a growth which springs from the connective-tissue 
cells, the latter from the epithelial. 

591. Varieties. — Sarcoma is divided into sarcoma of the cervix 
and sarcoma of the body. Sarcoma of the cervix occurs generally 
as grape-like clusters, protruding from the cervical mucous mem- 
brane, and it is also called sarcoma colli uteri hydropicum pa- 
pillae, and, from its grape-like appearance, sarcoma botryoides. 
From their soft appearance, they have been described as myxo- 
matous, but Pfannenstiel says this condition is due to a form 
of lymph edema. In the body of the uterus the disease may 
occupy the mucous membrane or the mural structure of the 
organ, and be either diffuse or circumscribed. Sarcoma of the 
uterine wall arises in either the mural portion of the uterus or 
from degeneration of a fibromyoma. The latter origin is regarded 
as the more frequent. It is often very difficult to make certain 
whether the disease has originated as a primary sarcoma of the 
wall or from a myoma. When it is recognized as situated in a 
myoma or surrounded by myomatous tissue, the latter is evi- 
dently its source. Where the myoma is associated with a sar- 
coma which involves the adjoining tissue as well, the origin may 
remain doubtful. Sarcoma of the mucous membrane overlying 
a fibroma is not infrequently observed. 

592. Pathology. — Sarcoma involving the mucous membrane 
occurs in the diffuse and polypoid forms. The former does not 
necessarily involve the entire surface, like a fungous endometritis, 
but appears as a more or less circumscribed growth, from the sur- 
face of which there are irregular projections, giving the new forma- 



774 



GYNECOLOGY. 



tion a roughened, often villous appearance. The polypoid variety 
is nearly three times as frequent, both in the body and in the 
cervix. Sarcoma of the mucous membrane is twice as frequent 
in the body as in the cervix. The grape-like clusters, already 
mentioned, protrude from the external os by the pedicle. The 
extremities of these are soft, oftentimes easily broken down, 
and they form a dense cluster, projecting from the os, in which 
the different portions of it are molded or flattened by pressure. 
They arise by a firm, more or less broad pedicle from the mucous 
membrane of the cervical canal and project from the external 
OS into the vagina, showing a great resemblance to the bladder 




Fig. 501. — Sarcoma of the Body of the Uterus. 

a, a. Characteristic appearance of blood-vessels minus distinct wall, the wall 

being formed by the malignant cells. 



mole. While the foundation part of the new formation of the 
cervical canal consists of firm, fibrous tissue, the vaginal portion 
is strongly edematous, soft, almost fluctuating, and easily broken 
down. The growth has a pedicle which is often thinned and 
drawn out, made up of a number of individual berries which 
are situated so close together that they are flattened. (Fig. 501.) 
These vary in size from a grain of corn to that of a grape, and 
their stalk shows a smooth, moist, glistening surface of a yellow- 
ish-white, brownish, or blue-black color, alterations which are 
produced by the entrance of blood into the tissues. The berries 
are most often bluish in color, and in some places vitreous 



GENITAL TUMORS. 775 

changes are seen. The berry contains a bright or Hght yellow 
fluid and collapses upon its escape. These projections, however, 
usually have about the appearance, if not the consistency, of 
a mucous polypus. The growth takes its origin from the superior 
layer of the mucous membrane and assumes the grape-like form 
only after its extrusion into the vagina. This form is produced 
by interference with the circulation from pressure upon the 
pedicle, which, as a rule, causes edema and swelling of the intra- 
vaginal portion. The disease progresses slowly, but is often 
carried and disseminated by the blood-vessels. The individual 
cells are mostly of the roundish or spindle form. Between them 
is almost uniformly found a very fine intercellular substance. 
Parts of the new formation are divided by fissures or ramifying 
spaces, which, from the high cylindric epithelium and the nuclei 
situated in the cells, are recognized as the cervical glands. These 
glands are not sufficiently numerous to justify the appellation of 
adenosarcoma, a term sometimes applied to the condition. The 
diffuse form aft'ects the body. Its progress is slow and it extends 
upon the surface, showing great reluctance to the invasion of 
the subjacent wall. As it follows the surface, it is manifested 
by large or small nodular papillary or villous projections. The 
mucous surface begins to degenerate and hemorrhage appears. 
In rare cases, the muscular structure is rapidly involved. Gener- 
ally the tissue involved has a reduction of its vascularity^ When 
the vessels are specially abundant, it is designated as the hemor- 
rhagic or telangiectatic variety. 

The appearance of a section of sarcoma is quite varied. The 
less the connective tissue present, the more homogeneous it 
appears. Most generally it is marrow-like, and, in advanced 
stages, presents a soft, smeary, and very fragile mass. With an 
increase of the connective tissue the borders are folded and irreg- 
ular, inclosing a homogeneous section. The structure undergoes 
marked changes under myxomatous alteration or serous penetra- 
tion, and not infrequently apoplectic nests are recognized and 
cysts are formed. 

The muscular walls are especially resistant, and become 
thickened, while the disease extends in the direction of the least 
resistance, which is into the cavity of the uterus. The uterus is 
usually not enlarged; when it becomes so, it is uniform. The 
uterus is hard or soft, according to the degree of extension. In 
rare cases the growth of the disease and uterine hypertrophy are 
simultaneous. Under these circumstances it attains to the size 
of a child's head; in rare cases it shifts to the internal os and 
causes severe hemorrhage, serous discharge, or purulent destruc- 
tion. In rapid extension the tumor can reach the ribs. Occa- 
sionally, it penetrates the uterine wall, projects upon the perito- 



776 GYNECOLOGY. 

neal surface, involves the peritoneum or the intestine, results in 
suppurative peritonitis, and death rapidly follows. It can become 
encapsulated and penetrate the intestine or the abdominal wall, 
and form a fistula. Fistulas of the rectum and bladder are rare 
in sarcoma, but frequent in carcinoma. The disease seems 
inclined to limit itself to the uterus, and metastasis to other 
organs occurs late. The disease can grow through the uterus 
and involve the parametric tissue, but this only in advanced 
cases. A polypoid growth may extend and fill up the uterine 
cavity and lie upon healthy tissue without involving it. 

Sarcoma of the wall appears in a rounded form, with folded 
or lapped borders. The uterus is hypertrophied. Section of 
such a tumor shows a yellowish-white or grayish -red surface. 
The discharge is a milky, soft tissue, and its structure would 
indicate that it had originated in a fibromyoma. It is very 
difficult to decide whether the myoma is a cause or a coincidence. 
A myoma is not infrequently situated near a sarcoma of the 
mucous membrane, from which it can become involved. Polypoid 
growths are occasionally the size of a fist, and may have a broad 
base or a long, thin pedicle. When a polypoid growth pushes 
into the cavity, the remaining portion of the mucous surface may 
remain long uninvolved. The existence of the new formation 
develops an inclination to expel it as a foreign body, by which 
the OS is dilated, and the tumor, hanging by a pedicle, is ex- 
truded into the vagina. Portions of the tumor may disintegrate 
and be discharged. The cervical form of the species is rare, 
but sometimes projects from the os as a grape-like cluster, which 
may fill out the vagina and may even project from the vulva. 
These polypi most frequently originate from the posterior cervical 
wall, and are soft growths, which show but little inclination to 
break down. 

A second form resembles the cancroid, but is softer, less easily 
broken down, and does not so rapidly seize upon the other lip. 
The spindle-cell structure predominates in the cervical tumors. 
Myxosarcoma and angiosarcoma are very frequent. Sarcoma of 
the cervix shows but little disposition to invade the uterine body 
or the vaginal vault. It most frequently penetrates the cellular 
tissue of the parametrium. 

Growths are described as spindle-celled or round-celled, ac- 
cording to the variety of these cells which predominate, as none 
are pure. The diseased structure is surrounded by a zone of 
irritation cells, which are difficult to distinguish from the small 
round cell. Weil reported the growths occurring in the relative 
frequency of 35 per cent, spindle-cell, 45 per cent, round-cell, 
and 25 per cent, mixed-cell tumors. 

Ruge recognizes four groups : First, giant-cell sarcoma. The 



GENITAL TUMORS. 777 

cells of the intervening gland tissue are largely increased. The 
cells — of round, sometimes spindle, form — are irregularly ar- 
ranged, and their nuclei often exceed in size the usual cells. 
Second, the intermediate tissue cells, which are changed in the 
large spindle form to resemble the decidua cells. They are dif- 
ferentiated by their size, situation, and irregular form. Third, 
small round or spindle cells, between which lie irritation cells. 
Fourth, smaller round-cell sarcoma, which shows a great increase 
of cells, irregular in size and form. 

The influence upon the glands of the mucous membrane gives 
variety. Generally, the glands are compressed and disappear, 
but occasionally they are retained, and form extensive areas 
within the tumor, producing what is known as adenosarcoma. 
The origin of sarcoma is difficult to fi.x; the microscopic appear- 
ance would indicate that it was from the coats of the vessels. A 
tumor in which there is a great increase of the vessels is known 
as an angiosarcoma. 

Disturbances in nutrition cause edema and swelling of the 
cells; this condition simulates myxomatous degeneration, and 
has been called myxosarcoma. Lymphosarcoma is the name 
applied to those cases in which the disease originates in, and 
follows the course of, the lymphatic vessels. Myosarcoma is an 
engrafting of the disease upon a fibroid, and the term adeno- 
sarcoma indicates that glandular tissue has been included within 
the growth. Fibrosarcoma usually exhibits a roundish growth. 
The entire new formation may present a degeneration into 
sarcomatous tissue, so that upon section it exhibits a soft, mar- 
row-like structure, or may be somewhat firm and uniformly 
opaque, with moist or mottled surface. Frequently the tissue 
resembles fish flesh. At other times the myoma has undergone 
sarcomatous change only in parts of its structure, and these 
points of degeneration give the section a striated appearance, in 
which the nodules are distinctly recognized. The sarcomatous 
degeneration is most frequently found in the center of the mass, 
so that it is surrounded by a myomatous crust. Gusserow's 
assertion that the fibrosarcoma continually loses its capsule is of 
no significance, for not every myoma has a capsule. 

Fibrosarcoma can attain an enormous size, forming a tumor 
which reaches beneath the ribs. If the tumor is projected into 
the uterine cavity, it is generally covered by the mucous mem- 
brane which is not penetrated by the disease, and occasionally 
the tumor, thus covered, is extruded into the vagina. The sub- 
mucous tumor mostly springs by a broad base from the wall of 
the uterus, in which no sarcomatous tissue is found. If the sub- 
mucous tumor has attained a large size, disturbances of nutrition 
may have already occurred, which lead to suppuration. The 



778 GYNECOLOGY. 

longer the growth exists, the greater the incHnation to destruc- 
tion, especially if it is soft and has grown rapidly. In the sub- 
mucous growth the uterus tends to enlarge, especially when the 
tumor is of the interstitial variety. On the other hand, the 
intraligamentary subserous sarcoma produces an enlargement or 
alteration of the uterus, which should not be overlooked. 

These sarcomata, like the myomata from which they mostly 
project, are but slightly supplied with vessels, though they fre- 
quently have a distinct telangiectatic form. 

Much diversity of opinion exists as to what constituent of the 
wall affords origin for the sarcoma cell. Virchow attributed it 
to the intercellular substance: "Their cells increase by division, 
they consist more and more of round cells, beginning small, later 
larger, with considerable nuclei, as large mucous bodies, while the 
intercellular substance is looser and more spongy." Kahlden 
believed that sarcomatous degeneration resulted from the imme- 
diate transformation of muscle-cells into roundish cells; their 
poles then became oval or blunted. Whitridge Williams says that 
under rapid increase of the number of cells this section of tissue 
passes into pronounced spindle-celled sarcoma with irritation 
cells. Ricker explains the growth "naturally by a growing 
through of myoma bundles by the side of the sarcoma tissue." 
Ruge says, "The impression exists, as if the fine, small muscle- 
cells passed over directly into the sarcoma cells." Gessner, from 
extensive investigations, concludes: "The round-cell sarcoma 
continually takes its origin from the connective tissue, and, like- 
wise, the majority of the spindle-cell sarcoma; but that in all 
probability to the smallest part they lead back to an immediate 
transformation of muscle-cells." 

593. Etiology. — The cause of sarcoma is unknown. Cohn- 
heim's theory that it originates from some congenital defect 
affords no further information. In other parts of the body sar- 
coma is attributed to injury, but the occurrence of rapidly 
developing sarcoma following trauma is no indication that the 
latter is the cause. Injuries during parturition, difficult delivery 
of the placenta, frequent labors, and blows upon the sacrum 
have been assigned as causes for its development. Labor, how- 
ever, does not seem to be a factor, as two-thirds of the cases are 
below the average in child-bearing, and in a great majority there 
is a long interval between the last labor and the development of 
the disease. The cervix is most subject to injury during labor, 
while the body of the organ is more subject to the disease. 

Predisposing factors are: Age. The cases of sarcoma of the 
mucous membrane preponderate between the ages of fifty and 
sixty, although a large number are found between the ages of 
five and twenty; sarcoma of the wall is absent in the young, 



GENITAL TUMORS. 779 

while the maxirauin number is found between the ages of forty 
and fifty. Trauma, parasitic irritation, syphilis, and the presence 
of fibroids are included, but, if factors, the query becomes im- 
portant, Why are the cases not more frequent? Gusserow 
believed that it originated from changes in the fibroid, and Mar- 
tin saw the disease follow the ergot treatment of fibroid in six 
cases. The latter number, however, is too small for a definite 
conclusion. Heredity as a factor is undetermined. Poverty has 
been given as a cause, but Weil has shown that one-fourth of 
the cases of sarcoma of the mucous membrane have occurred in 
the well-to-do. 

594. Symptoms. — Sarcoma, like carcinoma, presents no char- 
acteristic symptoms. The more important indications or signs 
which should awaken suspicion of its existence are hemorrhage, 
discharge, pain, and, in advanced stages, cachexia. In more 
than one-half of the cases bleeding is the first symptom, and 
is rarely absent. It begins by increased menstrual flow, then a 
bloody, watery discharge, which is not sudden, as in fibroma, 
but more or less continuous. It comes from the associated 
endometritis, while a stronger flow is indicative of destruction 
of the new formation. Rupture of vessels and more or less 
severe hemorrhage occur in the diffuse variety, but the polypoid 
form does not readily break down. In the cervical variety the 
disease occurs quite early in life. It has been observed at two 
and one-half years and displays a preference for the young at 
the period of awakening to sexual activity. The earlier symp- 
toms are similar to those of mucous polypus, such as hemorrhage 
and discharge. During sexual activity there is first increased 
menstruation, then irregular discharge of blood, later pain, 
which results from the pressure of the increasing growth upon 
the cerA^ix. The extension of the disease to the parametrium 
causes pressure upon the pelvic nerves and the formation of 
masses which press up the uterus and lift it out of the pelvis. 
The hemorrhage and diftuse discharge result in a high degree of 
anemia, and finally cachexia appears, and the patient ultimately 
perishes from marasmus and the penetration of the disintegrating 
tumor into the abdominal cavity with fatal peritonitis. In the 
frequently recurring sarcoma of the mucous membrane, which 
appears at the climacteric, hemorrhage is the first, and often for 
a long time the only, indication of the disease. The obstruction 
to the uterine discharge will frequently result in the formation 
of a pyometra or hematometra and the development of a tumor, 
which will reach to the ribs. The uterine collection may be bloody 
or mixed with tissue and it often attains an enormous size. Dis- 
charge is the first symptom in about one-fourth of the patients 
and does not cease with the further progress of the disease. It 



780 GYNECOLOGY. 

begins as a quite abundant, thin, watery fluid, which is later 
mixed with blood. Such a discharge continuing for a length of 
time as the only symptom should arouse a suspicion of the 
existence of sarcoma. It is true that discharges of this character 
are not rare as a symptom of submucous fibroids, but its occur- 
rence after the menopause is an almost positive indication of 
sarcoma. In the first stage there is no disagreeable odor beyond 
the stale sweetish smell, but with the destruction of the new 
formation the discharge becomes purulent, sanious, and has a 
foul odor. The carrion-like smell so characteristic of cancer is 
not usually present, because the large collections in the uterus 
are retained by the obstruction, and owing to the arrangement 
of the vessels are afforded better nutrition, so that the new 
structures do not so easily break down. The disease generally 
appears in the polypoid form. Sanious discharge occurs when 
the uterus forces the new growth out, the os is dilated, and the 
diseased mass is extruded into the vagina. The extruded parts 
are to some degree deprived of nutrition, and this results in 
further destruction. The discharge in the vagina has abundant 
opportunity for exposure to infection from saprophytes, which 
accelerate the rapidity of destruction. It is then mixed with 
ulcerative pieces of tissue, which are often thrown off in large 
masses, and these still further disintegrate in the vagina. A 
bloody discharge will follow and pyonietra can occur, but this 
never attains the same extent as the hematometra. Pain is 
absent at the beginning of the attack, but is aggravated with 
the increase in the size of the uterus, the persistent pressure in 
the pelvis, and the sensation of fullness in the abdomen. As the 
uterus becomes enlarged, pain is referred to the ileum or to 
the sacrum and radiates down the thighs. The extension of pain 
is due to the involvement of the uterine nerve-endings by the 
new formation. Pain is greatly aggravated when the disease has 
passed beyond the boundaries of the organ and infiltrated the 
pelvic tissues and made pressure upon the large nerve-trunks. In 
the polypoid variety the pain becomes labor-like when the struc- 
ture attains a size which leads the uterus to expel it. Painful 
attacks do not occur at such regular hours as in carcinoma. 
Inversion of the uterus has been caused by the efforts of the 
organ to expel its contents. Vesical symptoms are comparatively 
frequent when the disease is confined to the uterus and are 
manifested by more frequent desire to urinate, pain in evacua- 
tion, and distressing vesical tenesmus. These symptoms are 
more particularly seen in the circumscribed variety and are, con- 
sequently, not the result alone of increased weight. In advanced 
stages constipation is marked from pressure of the infiltrate upon 
the rectum and partly from decreased nutrition. Such patients 



GENITAL TUMORS. 781 

apply for relief from constipation and the pain at stool. The 
infiltration of the uterus can attain to considerable dimensions, 
but, unlike carcinoma, shows but little inclination to compress or 
involve the ureter. As the cervix is rarely involved, vesical 
and rectal fistula are infrequent. The constant drain will neces- 
sarily affect the general health and the cachexia is greater than 
in cancer. In sarcoma of the uterine walls, frequently known as 
fibrosarcoma, the great diversity of symptoms depends upon the 
situation of the disease, and makes it impossible to present a 
clinical history as in other forms of trouble. However, one of 
the first signs is an irregular bleeding, following the menopause, 
in a woman who has had a myoma. The myoma rarely delays 
the climacteric longer than the fifty-fifth year. The continuation 
of the menses at an advanced age or their return after ceasing 
should indicate the probable degeneration of an existing myoma. 
Following the climacteric, the myoma ordinarily ceases to grow 
or decreases in size, while a sarcoma of the uterine wall increases. 
A rapid growth subsequent to the climacteric is with rare ex- 
ceptions an indication of sarcomatous degeneration of a myoma. 
A symptom constant in sarcoma and always absent in myoma 
is a premature and rapid cachexia. From great loss of blood, 
the myoma may cause anemia, but the sarcoma causes emaciation. 
When the cachexia occurs without much loss of blood, it indicates 
an unfavorable influence upon the blood composition and forma- 
tion. The cachexia is preceded by a sense of weariness, pain 
in the head, nausea, sleepiness, and universal pain throughout 
the body. Furthermore, there is a sensation of tension in the 
belly without marked increase in the tumor. Difficulty with 
urination without compression is also present and disturbance 
of nutrition without other assignable cause is quite marked. A 
profuse watery mucous or watery bloody discharge occurs similar 
to that from an ulcerating submucous myoma, except that in 
the latter the growth is not discharged in pieces, but the tumor 
retains its integrity and disintegrates from the surface, while in 
sarcoma large portions of the mass are thrown oft' or are easily 
broken off by the hand. Pain is produced when the disease 
breaks through the walls of the uterus and undergoes great 
extension. Labor-like pains are caused if the uterus attempts 
to discharge its contents. Sarcoma occurs in but a small per- 
centage of cases of myoma, yet sufficiently often to justify it 
being reckoned as a factor. While the possibility of this de- 
generation is no indication that every patient suffering from 
myoma should be subjected to an operation, still it is a warning 
which should awaken suspicion when adverse symptoms develop 
in the tissue thus aft'ected. Paget described a peculiar form of 
this disease under the designation of recurrent fibroids. Whether 



782 GYNECOLOGY. 

in these cases successive mucous fibroids were discharged or the 
condition was sarcoma from the beginning only the microscope 
could have determined. Schroder made a vaginal extirpation in 
a patient from whom he had removed seven successive polypi, 
the last three of which were sarcomatous. The removal of the 
sarcomatous growth long years after previous removal does not 
prove that the former was malignant. The possibility of such 
changed tumors occurring should be decided by the more fre- 
quent examinations with the microscope, in order that extirpa- 
tion may be promptly resorted to when malignancy is demon- 
strated. 

It is asserted that metastasis is late in its occurrence in 
fibrosarcoma. This assertion is correct only as to the length of 
time symptoms exist prior to such manifestations, but does not 
indicate the long existence of sarcoma. 

595. Duration. — The duration of the disease in sarcoma of 
the cervix is about the same as that of cancer of the part — 
namely, about one and one-half years. It is more difficult to 
fix the term of the disease in the variety involving the uterine 
mucous membrane, as the earlier symptoms do not come under 
the observation of the physician. Cases have been reported as 
having survived several years ; the average duration, however, is 
about two years. The polypi is slower in its progress, probably 
dependent upon a slighter inclination of this form to invade the 
muscle wall. Metastases occur in about one-fourth the cases and 
affect any tissue in the body. The structures most frequently 
affected are the lungs, peritoneum, lymph-glands, and intestines. 
In the cervical variety it is likely to extend to the vagina, where 
the involvement is superficial and does not interfere with cure 
if extirpation of the uterus is performed, provided the operation 
is done early. To afford hope of recovery the diagnosis must be 
made early, and not after the recurrence of the disease following 
curetment or amputation of the cervix has demonstrated its 
malignant character. The polypoid growths from the cervix 
should be recognized by their peculiar appearance, and the micro- 
scopic examination of the cureted scrapings should render the 
diagnosis certain. The re -formation of the polypus should lead to 
the suspicion of malignancy, and a careful microscopic examina- 
tion should be made to determine its true character. In the 
fibrosarcoma it is still more difficult to fix the duration of the 
disease, as we have no means of knowing when the degeneration 
of the fibroid begins. Cases have been reported in which tumors 
existed for ten years. These are probably cases in which the 
myoma has existed for a long period and only in the later years 
become malignant. Metastases in this form appear late, follow 
the course of the blood-vessels, and, like the other forms of the 



GENITAL TUMORS. 783 

disease, involve the lungs, pleura, liver, rectum, omentum, and 
kidneys. Fibrosarcoma is frequently regarded as a compara- 
tively benign tumor, because it remains proportionately limited 
to the uterine cavity, but this is incorrect, for this property is 
common to mucous membrane sarcoma and cancer of the body 
of the uterus as well. If metastasis is any criterion as to malig- 
nancy, we must regard parenchymatous sarcoma as more malig- 
nant than the mucous, for in the latter metastases occur in 
only one-fourth of the cases, while in the former but one-fourth 
escape. Although it is impossible to fix the duration of life, it 
would seem to be longer than in the other forms of malignant 
disease. Its progress is attended with the same symptoms as in 
other forms of malignancy. Its termination is usually death 
from exhaustion, bleeding, and discharge, and by the further 
extension of the disease into the various parts of the body. 
Sepsis plays a less important part than in the mucous variety, 
and ulceration does not appear so frequently, and, when present, 
by the evacuation of the ulcerating mass does not usually cause 
general symptoms, though a purulent peritonitis has been fre- 
quently reported as a cause of death. 

596. Diagnosis. — Sarcoma of the mucous membrane can be 
accurately determined only by microscopic examination. Other 
means will be sufficient to render certain the existence of ma- 
lignant disease, but the variety is determined only by the micro- 
scope. Neither the condition nor symptoms offer anything char- 
acteristic of sarcoma, while a majority of the diseases of the 
uterus afford similar symptoms. 

An elderly w^oman with a large uterus, who suffers from a 
profuse watery discharge mixed with blood, should be suspected 
of having sarcoma. Submucous myoma sometimes causes a 
similar discharge, but the uterus is greatly enlarged, and it does 
not occur for the first time in advanced age, and is always accom- 
panied with bleeding. 

Senile endometritis may cause a profuse discharge, but the 
discharge is purulent, and generally has a disagreeable odor. 
The organ presents the characteristic changes of old age, and is 
not large. 

A second suspicious sign is vesical tenesmus, which should 
be regarded as an indication of malignant disease when no other 
cause exists. 

Sarcoma of the ttterine body is naturally difficult to diagnose. 
It can be completely covered by the cervix and the vaginal 
portion, and when a large cauliflower-like mass projects from the 
cervix, it can be either sarcoma or cancer, and the microscope 
only can determine which. In the differential diagnosis there 
are a variety of diseases which must make the diagnosis only 
probable. 



784 



GYNECOLOGY. 



The uterine body is always enlarged, but does not differ 
essentially from the enlargement of chronic metritis, myoma, 
and carcinoma. The sarcomatous uterus is not so hard as the 
myomatous organ. In malignant disease the very much en- 
larged organ indicates sarcoma, but the carcinoma may be super- 
imposed upon a myomatous uterus. In the latter the form of 
the uterus is irregular. 

Fungous endometritis, a mucous polyp, and submucous fibroid 
may require the use of the microscope to differentiate them. 





Fig. 502. — Fibroma Undergoing Sarcomatous Change. 



Positive proof of malignant disease is not obtainable by the 
touch. A sensation of softness is common to mucous polypi, 
submucous myoma, and mucous membrane sarcomxa. Pieces of 
the latter can be broken off' with the finger, as also from other 
growths when ulcerating. Touch with the finger is not always 
free from danger. It will be safer to employ the microscope upon 
the scrapings obtained by curetment. 

The inexperienced investigator may be confused by the resem- 



GENITAL TUMORS. 785 

blance between sarcoma and interstitial endometritis, with more 
or less destruction of the glands. In doubtful cases examine all 
the parts removed before making the decision that malignant 
disease does not exist, and, if then in doubt, keep the patient 
under close observation. If she continues to bleed, make a 
second curetment, and again examine the scrapings. 

The abundance and variety of the cells in a specimen are of 
significance in the diagnosis of sarcoma. In round-cell sarcoma 
the cells are round and thick, and exceed in size those of the 
intermediate gland tissue, between which are found irregular 
cells. Kellar places particular stress upon the fact that the indi- 
vidual nucleus is differently formed and varies in the way it 
accepts the color stain, so that the smaller nuclei are always 
better colored than the larger. When the glands are absent, the 
cells are usually pressed together and the epithelium is flattened. 
If the glands have largely decreased in interstitial endometritis, 
there are distinctive traces of connective-tissue formation in the 
intervening structure, which is penetrated in all directions by the 
migration of connective-tissue cells. They differ from spindle 
cells in that the long axis is drawn out at the ends, and the long 
axis of the nucleus does not fill out the body, while in the spindle- 
cell sarcoma the cells are smaller, plumper, only rarely with 
pointed ends, and the nucleus almost fills out the body. 

The distribution of the vessels is also very significant. In 
benign changes of the endometrium the blood-vessels are few, and 
present distinctive walls, while in sarcoma they are much more 
abundant, and appear in immediate relation to the surrounding 
tissue of the growth. Amann asserts that the recognition of 
abundant nuclear division can be employed for the diagnosis of 
sarcoma. 

In the differential diagnosis of subinvolution of the decidua 
and incomplete abortion the clinical history is of advantage ; but 
if long-continued, irregular menstruation is followed by severe 
hemorrhage, perhaps an offensive discharge, while the uterus 
remains large and not especially hard, confusion with sarcoma is 
possible, which will require the microscope for confirmation, and 
then not always with certainty. The individual decidual cells 
closely resemble those of sarcoma of the mucous membrane. The 
retained tissue glands will present the alterations of pregnancy in 
their epithelium to such a degree that the error is easily avoided. 
The difficulty will be greater when a retrogression of the decidua 
has occurred, for the uniform structure of the decidua is de- 
stroyed. In single sections, however, individual islands of the 
decidual structure will be found, while other sections will show a 
great irregularity in the cells. The size of the cells is quite 
variable ; frequentlv the decidual cells show a pronounced spindle 
50 



786 GYNECOLOGY. 

shape, and penetration of the tissues by round cells exists, so 
that a structure is formed which is extraordinarily like a sarcoma. 
Differentiation is easily accomplished in such cases by demon- 
strating the chorionic villi. If we find the decidual cells by curet- 
ment of a woman who has had an abortion months before, we 
will also find the chorionic villi present, for the decidual cells 
are not otherwise so long retained. In the absence of the chori- 
onic villi the diagnosis is fixed by finding, near the large decidual 
cells, sections of tissue which show the unaltered mucous mem- 
brane with retained glands or with the recognizable alterations 
of interstitial endometritis. 

Tuberculosis of the endometrium, by the premature loss of the 
glands, through the appearance of numerous round cells in the 
tissue, and the occurrence of irritation cells, causes confusion with 
sarcoma. The clinical history, the demonstration of caseation, 
the peculiar irritation cells of tuberculosis, and the rarely demon- 
strated tubercle bacilli will protect against confusion. 

Carcinoma of the Uterine Body. — There are certain forms of 
cancer which can not be distinguished microscopically from sar- 
coma. We can, however, determine that malignancy is present. 

As in the mucous sarcoma, the diagnosis is made only by 
microscopic examination of the discharged or removed pieces of 
the growth. Greater difficulties are experienced in securing the 
material for study than in the latter. A suspicion that fibro- 
sarcoma exists should be awakened : 

First, if a myomatous tumor does not cease to grow after 
the menopause. , Rapid growth does not always follow sarco- 
matous degeneration. 

Second, if a woman with a myomatous tumor commences to 
bleed after the menopause. In rare cases this may occur in 
advanced age from mucous polypi, but the association of a pro- 
fuse watery discharge should be held to be very suspicious of 
sarcoma. 

Third, if with a myomatous tumor cachexia occurs. Through 
excessive bleeding myoma causes anemia, but never cachexia. 

Fourth, if a myomatous tumor occasions symptoms which are 
explainable neither by the size nor the situation of the tumor. 

Fifth, if ascites complicates the tumor. The possibility of its 
being caused by other conditions must be excluded. Ascites 
occurs from penetration of the peritoneum by the disease, and 
may follow a subserous tumor which has become sarcomatous. 

Sixth, if a myoma which was previously hard grows rapidly, 
and becomes soft and swollen. 

Seventh, if after the removal of a fibrous polypus another 
follows. 

597. Recurrence. — The tendency of the disease to return even 



GENITAL TUMORS. 787 

seems greater in the fibrosarcoma than in the mucous growth. 
It is probable that the explanation of the greater frequency of 
the occurrence in the former is due to the early recognition and 
more prompt treatment of the latter. When a case of mixed 
sarcoma remains a year free from recurrence it may be con- 
sidered as cured, but not so the fibrosarcoma, for it has been 
known to return at a much later date. The great difficulty in 
the treatment of this as in all malignant disease is the impossi- 
bility of determining the diagnosis before the disease has ex- 
tended beyond the point at which it can be surely removed. 
Our results must continue bad until both patient and physician 
have learned to realize that uterine hemorrhage is a symptom 
which demands prompt and thorough investigation. When the 
disease has so extended that a radical procedure is no longer 
indicated, we direct our efforts to the arrest of hemorrhage, the 
decrease of discharge, and the improvement of the general condi- 
tion of the patient. 

Chorio -epithelioma. — This is a condition which it will often 
be possible to determine by touch through an accessible cervical 
canal. But little satisfaction will be secured by examination of 
the tissue removed by the curet, as it will consist mostly of blood- 
clot containing a few pieces of necrotic tissue. 

598. Treatment. — -Whenever possible, the uterus should be 
extirpated. No other measures are worthy of consideration, but 
the case must come under observation sufficiently early to admit 
of the extirpation of the organ within the limits of healthy tissue. 

Operation is contraindicated when the disease has so broken 
down the system of the patient that she will be unable to en- 
dure the ordeal of a radical procedure. It is also contrain- 
dicated when the growth is no longer confined to the uterus. 
The existence of metastases and the extension of the disease 
beyond the confines of the uterus would render operation of no 
avail. This assertion does not apply to extension upon the 
vagina, if the disease can be removed. The existence of 
ascites must not infiuence against the procedure unless the 
involvement of the retroperitoneal glands can be demonstrated. 
The removal of the entire uterus, even in slight cases, is indicated, 
because it affords greater immunity against return than any 
partial operation. When the size of the uterus permits, the 
operation should be performed by the vagina. This can usually 
be done in cases of mucous sarcoma, as the organ is rarely of 
large size. The fibrosarcoma may often be scraped out and 
the size of the organ may be reduced by the administration of 
ergot for a few days, and then the vaginal operation may be 
performed. It is unwise to subject the healthy tissues to in- 
fection by cutting up the tumor to reduce its size. 



788 GYNECOLOGY. 

599. Treatment Following Operations for Malignant Dis- 
ease. — The patient should be kept in the horizontal position, 
though she may be permitted to change from one side to the 
other frequently. The urine should be emptied with the catheter 
only when she is unable to void it spontaneously. The bowels 
should be evacuated at the latest by the third day. She should 
be given: 

li . Hydrarg. chlor. mitis, gr. i 

Sodii bicarb., gr. ij. 

M, ft. capsul. No. I. S. — One capsule every fifteen minutes until gr. 
iss-ij are taken. 

And this should be followed by either a seidlitz powder, effer- 
vescent magnesia citrate, eight ounces, or magnesia sulphate, 
dram i every hour, until a free evacuation is secured. The 
appearance of tympanites should indicate the employment of 
stimulating enemata to promote increased peristalsis. An 
enema of alum, one ounce to the quart of warm water, is very 
effective in promoting evacuations of gas. 

If the abdominal wound is closed, the vaginal tampon of 
gauze may be permitted to remain for from six to nine days. 
After purification of the vagina the gauze should be replaced. 
If the stumps have been tied with silk, it is not always possible 
to remove them all, and granulations often spring up about 
the ligatures and grow into the vulva, resembling a raspberry. 
With such a growth may result a similar process in the mucous 
membrane, so that a hen's-egg-sized growth projects from the 
angle of the vagina, which readily bleeds upon being touched, 
and at once awakens a suspicion of recurrence. Bimanual 
examination, and especially a microscopic investigation, will 
disclose its true character. In the third week the patient is 
permitted to arise, and in the fourth to go about the house. 
When clamps are used instead of ligatures, the weight and 
dragging of these instruments increase the pain. The distress 
is aggravated by every movement, and frequently morphin 
may be required to make it endurable. The difficulty is often 
increased as early as the day after the operation by an accu- 
mulation of flatus. In the majority of cases the difficulty 
appears later, and is relieved only after prolonged rectal ir- 
rigation. The meteorism, increased abdominal sensibility, en- 
hanced rapidity of pulse, and elevation of temperature pro- 
duce anxiety, which is aggravated by prolonged vomiting 
and other signs of ileus. A number of cases are reported of 
a fatal result from kinking of the intestine. The continuation 
of such symptoms should lead to removal of the gauze, for 
fear that it is causing the obstruction. This is done with the 
recognition of the fact that the adhesions are not firm, and 



GENITAL TUMORS. 789 

that trouble can arise from its premature removal. The cavity 
should be tamponed lightly. In the removal of the gauze care 
must be exercised that a knuckle of intestine is not drawn into 
the vagina. Such an accident occurred in one of my patients, 
where the interne withdrew the gauze and found that there 
was a large coil of intestine in the vagina, which he could not 
replace. I placed the patient upon her side with the hips ele- 
vated, and had no difficulty in replacing the intestine, which 
was kept in place by a gauze tampon. As to how long the 
gauze shall remain, operators differ — from the one or two days 
of Doyen to the ten days of Zweifel. The latter prefers the 
longer period because the earlier removal of the gauze breaks 
up the adhesions and draws down the intestines; at the later 
period the gauze has become loosened and the intestinal ad- 
hesions are so firm that they are undisturbed. 

The clamps are generally removed at the end of forty-eight 
hours. Landau and Seligman remove them on the second day. 
I have had several, cases of quite severe hemorrhage after re- 
moval at the end of forty-eight hours — hemorrhage which 
is difficult to control. The occurrence of hemorrhage requires 
resort to exposure of the cavity by retractors, and the ligament 
must be followed up and the bleeding vessels again secured 
with forceps. 

Another objection to the use of clamps is the danger of 
injury to the ureter and the bladder, but this is due to want 
of care in pushing away these organs, and is just as likely to 
occur from careless use of the ligature. Injuries of the rectum 
are also reported, but are less excusable than those of the urinary 
apparatus. Among the causes of fatal resuh sepsis is the most 
frequent. 

FALLOPIAN TUBES. 

600. Tumors (Benign) .^Tumors or growths of the tubes 
are exceedingly rare, except as a result of inflammatory changes. 

601. Fibroma or myoma is infrequent and of small size. It 
develops from the muscular tissue of the tube, and may grow 
inward or become subperitoneal, but rarely obstructs the lumen 
of the tube. Inflammatory and tuberculous changes have 
been mistaken for myoma, particularly the condition known 
as salpingitis nodosa. Under the name of adenomyoma or 
cystadenoma Recklinghausen describes a peculiar form of 
myoma which occurs only in the uterus and tube. It is char- 
acterized by the usual constituents of the fibroid, which include 
glandular structure. In the tube he attributes it to some re- 
mains of the primordial structure — the Wolffian body. 

602. Fibrocyst. — A unique new formation is described by 



790 GYNECOLOGY. 

Sanger-Barth which consists of three tumors collected from 
a conglomeration of various large cysts and firm tumors that 
were in part pedunculated from the fimbria of an otherwise 
healthy tube. Microscopically, the wall of the cyst consisted 
of fibrous connective tissue with smooth muscle-fiber, and, 
within, a nest of embryonic tissue. Its surface was covered 
with ciliated epithelium, and the contents of the cyst were 
detritus. The principal mass of firm tissue partly consisted 
of gelatinous myxomatous and partly of loose cell tissue. The 
products greatly resembled a teratoma. 

603. Enchondromata are small, semitransparent, cartilagin- 
ous masses, which are occasionally situated upon the ends of 
the fimbriae. 

604. Dermoid of the tube is exceedingly rare. Ritchie de- 
scribes a plum-sized bone removed from a dermoid of the 
tube. Pozzi, in a recent edition of his work, presents a diagram 
of a dermoid cyst removed from the tubal wall, which was ad- 
herent to the ovary. It had developed within the tube and 
ulcerated through the overlying wall. 

605. Cysts of small size are frequent, though their true 
cystic character is denied. The large irregular bullae so common 
in association with fibroid growths are said to be dilated lymph- 
spaces. Cysts varying from the size of a pea to that of a walnut 
are found in all the walls of the tube, but most frequently be- 
neath the peritoneum. Cysts within the tube are not infre- 
quently the result of inflammatory changes by which the ad- 
joining folds of the mucous membrane become adherent. Cysts 
of the tubal fimbriae become pedunculated and resemble the 
hydatid of Morgagni, which is by some regarded as a cyst. 
The cysts contain clear serum, colloid masses, or chalky bodies. 
Sanger divides these cysts into: 

1. Serous cysts, which arise by the accumulation of serous 
fluid between the lamella of the new mucous membrane. They 
can attain the size of a child's head, and may be either single 
or double. 

2. Lymphangiectasia and lymphangiectatic cysts in three 
forms: (a) As small vesicles upon tube and ligament, identical 
with those of older authors; (b) winding, ramifying tubes with 
constrictions and cystic distentions ; (c) lymphangiectatic cysts — - 
large, tough-walled, isolated cysts in the tubal serous cover- 
ing or the mesosalpinx. The two latter occur especially with 
uterine myoma. 

3. The hydatid of Morgagni, regarded as a physiologic cyst 
of the end of a tubal flmbria. 

Inflammatory cysts of the tubes— known, from the character 
of their contents, as hydrosalpinx, pyosalpinx, and hemato- 



GENITAL TUMORS. 791 

salpinx— have been discussed under inflammation. (Section 

383-) 

606. Polypus is a rarely recognized growth. Lewers re- 
ports a case in which, upon the inner surface of each dilated 
tube, were numerous growths, varying in size from a pin's 
head to a pea. Amann speaks of a growth of the mucous mem- 
brane consisting of connective tissue covered with enormously 
folded cylinder epithelium. Rokitansky and Klob describe 
connective growths of the fimbrias. 

607. Papillomata, denominated by Sutton as adenomata, 
are allied to the condylomata, or warts, found upon the vulva. 
The villus consists mainly of epithelium. Sanger has collected 
six cases, and divides them into two forms: (i) Simple cystic; 
(2) hydropic. 

The simple cystic is an indefinite soft growth from the mucous 




Fig. 503. — Papilloma of the Fallopian Tube. 

membrane, of a cauliflower-like appearance (Fig. 503), and its 
villous structure may fill out the tube and distend it into a 
considerable sized tumor. 

In the second form (cystic and vesicular papillomata) the 
tubal end becomes closed and the villi are so swollen as to give 
the appearance of a cystic mole. This form differs from the 
first in the greater size of the cavity from the inner surface of 
which spring the papillary masses. Doran and Sutton have 
attributed the occurrence of papillomata to previous gonorrhea, 
but with such a cause they should occur more frequently. They 
are difficult to differentiate from sarcoma and cancer. Their 
benignity, however, is proved by the absence of any tendency 
of their epithelium to atypic growth, and there are no metastases. 

608. Malignant Tumors. — Carcinoma of the tube may be 



792 GYNECOLOGY. 

either primary or secondary, though the latter is the more 
frequent. Secondary involvement of the tubes from cancer 
of either the ovaries or the uterus is comparatively late, as we 
not infrequently find the ovary forming a large tumor from 
cancer or sarcoma without any involvement of the tube. Doran 
divides primary cancer of the tube into two forms: 

1. When the cancer develops in the mucous membrane 
of a normally formed tube. 

2. When it forms in a malformed tube bearing a cyst the 
wall of which becomes infected. 

In the first form its situation shows its origin in the papil- 
lary structure — whether from degeneration of papilloma, as 
believed by Doran, or directly from the tubal mucous mem- 
brane, as asserted by Sanger-Barth, remains to be determined. 
The occurrence of the disease in the middle and external por- 
tions of the tube indicates that it is a sequel of inflammatory 
trouble. 

In the second form the disease develops in a cyst of the 
ostium. Doran describes a specimen in which the end of the 
right tube was dilated for an inch and a half, was very tortuous, 
and formed a tumor an inch in diameter at its widest part. 
In its wall was a solid deposit, over a quarter of an inch in thick- 
ness. At its outer part it communicated with a thin-walled 
cyst, situated in the anterior part of the broad ligament, lifted 
up its anterior fold, and raised the serous coat of the uterus. 
The cyst was about six inches in diameter, and its interior 
contained a thick deposit which appeared encephaloid in char- 
acter. Under the microscope the stroma was scanty, with wide 
alveoli containing great masses of cubic epithelial cells, as in 
encephaloid cancer. 

Amann is inclined to believe that cancer of the tube will 
prove to have developed through metastases from the uterus. 
The disease is generally confined to one tube. The recognition 
of its existence is necessarily difficult. When, after previous 
pelvic inflammation, a patient w^ho has reached her forty-fifth 
year shows a sudden or steady growth of subjective and ob- 
jective symptoms, cancer, says Doran, may be suspected, and 
watery or sanious discharges greatly increase the suspicion of 
malignancy. 

Treatment should consist in the prompt removal of all 
infected structures. 

609. Sarcoma of the ovary is frequent; of the tube, ver^^ 
rare. Occasionally, the sarcomatous nodules are found scattered 
over the peritoneal surface of the tube, but the disease more 
frequently passes from the ovary to the omentum. Kahlden 
reports a case in a woman of fifty-one years, in which the tube 



GENITAL TUMORS. 793 

formed a sausage-shaped mass filled with soft caulifiower-like 
material. Under the microscope it showed various degenera- 
tions, such as round-cell and spindle-cell sarcoma, and a papil- 
lary structure wanting in connective tissue. These forma- 
tions were found to arise from the endothelium of the lymph- 
vessels, which was increased several layers. As important 
constituents could be shown irritation cells similar to those 
in sarcoma. 

6 10. Chorio-epithelioma Malignum. — Just as malignant de- 
generation can occur in a portion of placenta or chorion Avhich 
is retained in the uterus, and produce a large tumor and subse- 
quent metastatic deposits in the abdominal and thoracic viscera, 
a similar malignant change may follow an ectopic gestation 
in the tubal sac. Sanger advances this as an additional argu- 
ment for active interference in such cases, and for the extir- 
pation of tubal moles and of the appendages when tubal abor- 
tion has occurred. 

BROAD LIGAMENTS. 

6ii. Cysts of the broad ligament varying in size from a 
pea to a pigeon's egg are frequent, and generally of but little 
clinical interest. They may be situated upon the surface of 




Fig. 504. — Eroad Ligament Cyst. 
T. Fallopian Tube. P. Parovarium. O. Ovary. 

the ligament or may lie deeply within its folds. Their walls are 
thin and the contents of the cyst consist of a watery^ or pale 
colored fluid. Superficial cysts are of undetermined origin, 
while the deeper growths are attributed to changes in the par- 



794 GYNECOLOGY. 

ovarium. I recently removed a multilocular cyst fromi the 
anterior surface of the broad ligament by opening the over- 
lying peritoneum and enucleating the cyst. The ovary was 
not affected and was left undisturbed. These cysts are fre- 
quently pedunculated, but rarely attain to any great size. 
They are generally called microcysts, and are often developed 
in the structure or suspended from the organ of Rosenmiiller. 
Only those which develop from the vertical tubes of the parova- 
rium have ciliated epithelium and are liable to form papillary 
growths subsequently. 

Parovarian Cysts. (Section 628.) 

612. Echinococcus cysts are rare, except in certain districts, 
notably Iceland and Mecklenburg. They primarily occur in 
the pelvic connective tissue, and always near the intestine. 





Fig. 505. — Broad Ligament C :th Torsion of Its Pedicle. 

The wandering of the parasite causes a chronic inflammation, 
characterized by round, elastic tumors situated near the rectum, 
which are slightly movable, but not painful. Bimanual pal- 
pation reveals that they are not connected with the uterus 
or ovaries. A positive diagnosis is to be determined only by a 
careful examination of the fluid obtained from the cysts, either 
by spontaneous rupture or by puncture. The danger of in- 
fection from it is so great that the certain determination of 
the disorder will not compensate for the increased peril induced 
by the puncture. 

Treatment. — The proper plan of treatment consists, when 
possible, in the removal of the sac. If we are unable to scoop 
out the cyst, then it should be fastened to the abdominal wall 
and drained. Pozzi advocates, when we have had to open 



GENITAL TUMORS. 795 

the peritoneal cavity, that the opening over the cyst should 
be packed with iodoform gauze for from twenty-four to forty- 
eight hours, until adhesions have formed, before the cyst is 
opened, when it can be done without danger of infecting the 
peritoneal cavity. If the tumor is situated low in the pelvis, 
a vaginal incision should be preferred. The sac cavity should 
be emptied and packed with gauze. 

613. Parovarian Varicocele. — Phleboliths. — A varicose dila- 
tation of the veins of the pelvis is common, and frequently, 
according to Klob, results in the formation of phleboliths. Their 
frequent occurrence is attributed to the rare presence of valves 
in the veins of the broad ligament. These masses attain the 
size of a pea or bean, and occasionally cause inflammation 
and thrombus formation. When situated so that they can be 
palpated through the vagina they are often mistaken for ureteral 
calculi. 

614. Lipomata. — Small collections of fat are not infrequently 
found in the mesosalpinx of the broad ligament near the under 
surface of the tube. They can attain the size of a bean, oc- 
casionally the size of a walnut. 

615. Fibroma. — -As the same muscular structure is found in 
the broad ligament as in the uterus, it is not surprising that 
fibroids should occasionally be found in the ligament independent 
of the uterus and its structure. Such growths may spring 
from the round ligament or are found in the broad ligament. 
The latter have been considered as aberrant uterine fibroids 
which have become separated from their first attachment. 
Sanger found these growths most frequently upon the right 
side. They may be situated intraperitoneally, in the fold 
of the groin, or in the labium ma jus. The mass may have a 
pedicle or may be sessile. It does not attain a large size, is 
quite movable, and is not painful. The condition may be 
confounded with fatty hernia, an epiplocele, or an ovarian 
hernia. The fatty hernia is frequently reducible, painful to 
the touch, quite soft, and ill defined. The irreducible epiplocele 
becomes like a fibroid, but has a cord stretched behind the 
abdominal wall. In an ovarian hernia the tumor retains the 
shape of the organ, is exceedingly sensitive, and increases at 
each menstrual period, while the uterus is displaced to one 
side. The treatment is extirpation. 

616. Malignant Growths. — Carcinoma and sarcoma of the 
broad ligaments are usually the result of extension of the dis- 
ease from the uterus or ovaries. The rectum, the bladder, or 
the retroperitoneal glands may be the source of the infection. 



796 GYNECOLOGY. 



OVARIAN TUMORS. 

617. Characteristics. — The tumors of the ovaries differ from 
the neoplasms of the other portions of the genital tract in their 
greater propensity to malignant degeneration, often rendering 
it difficult to determine whether an individual growth is malig- 
nant or benign. For this reason we will depart from the cus- 
tom we have previously followed and discuss the two classes 
of tumors together. 

618. Classification. — The tumors of the ovary are divided: 



Clinically 



Simple. 
Cystic -l Proliferating, 
i Dermoid. 
f Fibromata, 
e T/i J Sarcomata. 
^°^'^ I Carcinomata. 

[ Endotheliomata. 
Simple. 

Pathologically I Proliferating. 

' Dermoid. 
L Parovarian. 

According to size J Small. 

I Large. 

Cysts may originate in any part of the tubo-ovarian struc- 
ture, as the cortical, medullary, or parenchymatous portions 
of the ovary; in the structure between the tube and ovary 
known as the Rosenmiiller organ or parovarian structures; 
and in the hydatid of Morgagni, the extremity of the canal 
of Miiller. We have already spoken of cysts which develop 
in the folds of the broad ligament and are recognized as broad 
ligament cysts. Cystic growths may become of almost un- 
limited size, larger than any other growth of the body, and 
occasionally the body may seem but an appendage of the tumor. 
These growths repeatedly reach the weight of 100 pounds. 
Maritan reported an ovarian cyst weighing 200 pounds removed 
from a woman who previously weighed 290. (Fig. 506.) Her 
girth measure was ninety inches. Bullitt removed a tumor 
whose sac and contents weighed 245 pounds. 

The solid tumors are much less frequent than the cystic and 
closely retain the shape of the ovary. The cystic are irregularly 
spheric, the more spheric, the larger they become. As a rule, 
the surface is a bluish- white, greenish, brownish, yellow, or 
a glistening white. Secondary developments may occur in the 
wall, giving it an irregular shape, or it may consist of a large 
number of small cysts, which give the impression of a solid 
tumor. 

Cysts are still further divided into unilocular or single cysts. 



OVARIAN TUMORS. 



797 



and multilocular, where the sac is composed of a number of 
cavities or smaller cysts. Careful examination of a unilocular 
cyst will not infrequently show smaller cysts within its walls. 
The contents of the various tumors greatly differ; indeed, 
the different cysts in the same tumor show radically different 
contents. In the unilocular tumors the contents are usually 
clear and limpid; in the multilocular, thick, viscid, and glue- 




Fig. ::o6. — Large Ovarian Tumor. 



like in some, clear and limpid in others, while, from various 
causes, there may be discoloration by an admixture of blood, 
pus, or fat. 

The broad ligament cysts are generally unilocular and con- 
tain a clear fluid; those which originate in the hilum are papil- 
lary; and those from the parenchymatous structure of the 
ovary, glandular. 



798 GYNECOLOGY. 

Small Cysts. — The small cysts comprise: 

Small residual cysts. 
Follicular cysts. 
Cysts of the corpus luteum. 
Tubo-ovarian cysts. 

The large cysts are: 

Glandular proliferous. 
Papillary proliferous. 
Dermoid. 

r Hyaline. 
Parovarian < Papillary. 

i Dermoid. 

619. Small residual cysts are growths which develop in 
the structure between the tube and ovary, known as the par- 
ovarian structure, or the organ of Rosenmuller. Those which 
develop in the vertical tubes have ciliated epithelium, and may 




Fig. 507. — Small Residual Cysts. 

subsequently develop into papillar}^ growths. They may be- 
come detached from the ligament and hang from the perito- 
neal surface by a slender pedicle. It is possible that from these 
cysts may originate large cysts filled with either fluid or papil- 
lary contents. 

Attached to the fimbriated end of the tube is generally 
found a small cyst, varying in size from a pea to a cherry, known 
as the hydatid of Morgagni, which, from its almost continuous 
presence, is regarded as a physiologic cyst. This hydatid is 
the termination of the duct of Miiller. It is transparent, has 
a thin wall, and has a pedicle often a full inch in length. Doran 
describes a supratubal cyst of similar size, appearance, and 
structure, which he supposes to be a microcyst of the broad 
ligament in this anomalous position. 



OVARIAN TUMORS. 



799 



620. Simple or Follicular Cysts. — Hydrops Folliculorum. — 

These cysts are unilocular dilated follicles, generally multiple 
and small. In an ovary that has not attained to twice its 
normal size, fifteen to twenty of these cysts may be found. 
When small, the ovary is but slightly enlarged and the follicle 
projects upon the surface or lies embedded in the stroma. These 
cysts were long considered the sole source of large ovarian 
cysts, but it is only in rare instances that they attain the size 
of a fist, occasionallv of a man's head. The contents of the 




Fig. 508. — Cyst of the Corpus Luteum. 



cyst are generally clear, but may be blood-stained, and have 
a specific gravity of from 1005 to 1020. The cyst-wall is a 
transparent, thin membrane of a light gray color, covered with 
columnar epithelium. The cysts may be few and the stroma 
excessive, or the former may be very numerous and the latter 
scanty. When the latter condition is present, the ovary is- 
frequently converted into a mass of delicate cysts. It is not 
unusual to find an ovarv otherwise health v containing a uni- 



800 GYNECOLOGY. 

locular cyst the size of a hen's egg. The disease is generally 
bilateral. 

Etiology.— These cysts, even when large, are regarded as 
unruptured and dilated Graafian follicles, because of the grada- 
tions observed between them and the smaller cysts. In the 
smaller ones ovula may be detected, which have been destroyed 
or have escaped observation in the larger. Failure to rup- 
ture and increase of the fluid contents produce a dropsy of the 
follicle. The normal rupture may be prevented by undue 
thickness or toughness of the walls, the result of inflammation; 
by deposits of exudation over the surface of the ovary; or by 
the deep situation of the developing follicle; or failure may 
be the result of too slight congestion, which, though increasing 
the secretion, is too gradual to produce rupture. Such cysts 
have preceded menstruation, being occasionally found in the 




Fig. 509. — Tubo-ovarian Cysts. 

fetal ovary. These cysts rarely give rise to symptoms, as men- 
struation, ovulation, and pregnancy continue. 

621. Cysts of the Corpus Luteum.— These are unilocular 
cysts the size of a pigeon's egg, occasionally as large as an apple. 
They were first described by Rokitansky, who believed that 
only the corpus luteum of pregnancy could be thus transformed, 
but such cysts have been found in nulliparae. (Fig. 508.) The 
cyst -wall is comparatively thick, lined by a yellow, apparently 
folded membrane, in which microscopic examination shows 
the bud-like papillae characteristic of the corpus luteum. The 
recognition of this structure prevents their confusion with 
follicular cysts, or even with suppurative ovaritis. 

622. Tubo-ovarian Cysts. — An ovarian cyst in contact with 
a distended tube not infrequently results in the formation of 
a tubo-ovarian cyst. (Fig. 509.) The tubal inflammation 
early results in the formation of extensive adhesions flxing the 



OVARIAN TUMORS. 



801 



tubal ostium to the ovary. The increasing pressure of the 
accumulating fluid gradually absorbs the thin septum until 
the two sacs form one cavity, the smaller portion of which is 
usually formed by the tube. It does not generally attain a 
large size. The uterine end of the tube may remain permeable, 
and, as the fluid increases, permits the excess to drain through 
the uterus, forming a 
condition known as pro- 
fluent tubo-ovarian hy- 
drops. It resembles the 
condition engendered in 
hydrosalpinx, known as 
hydrops tubes profluens. 
The open tube acts as a 
safety-valve, preventing 
the increase and over- 
distention of the cyst, 
frequently leading to its 
complete collapse after 
every evacuation. 

623. Glandular Pro- 
liferating Cyst. — This 
class of cysts comprises 
the great majority of 
ovarian tumors, and 
they vary from the size 
of an egg to that of a 
tumor weighing over 
two hundred pounds, 
which may fill up the 
entire abdomen and en- 
croach upon the thor- 
acic viscera. The sur- 
face of the cyst presents 
a pearly -white, glisten- 
ing appearance, the 
thinner portions of 
which are purple, green, 
or black, according to 
the color of their indi- 
vidual contents. The 

external surface may be smooth, oily, and covered with papil- 
lary growths or mucous vegetations. (Figs. 510 and 511.) 

The term proHferous is apphed to those which are highly 
organized and abundantly supphed Avith blood-vessels. The 
term proHgerous is given to cysts that have the faculty of budding 

51 




-Large Ovarian Cyst, 
ricrht. 



Patient Up- 



802 



GYNECOLOGY. 



or generating new cysts from or within the original growth. 
They may be spheric in shape and regular in outline, simu- 
lating a single cyst, or may be irregular from the numerous 




Fig. 511. — Ovarian Cyst. Patient Recumbent. 

nodules, indicating the presence of a multilocular tumor. These 
growths generally have a distinct pedicle. 

624. Pedicle. — The attachment of the tumor may be pedun- 
culated or sessile. The latter are frequently intraligamentary. 
The pedicle may be long or short, thin and band-like, or broad 




Fig. 512. — Pedicle of an Ovarian Cyst. 



and thick. It is developed by the traction of the tumor and 
the resulting hyperplasia of the ovarian ligament, and by stretch- 
ing of the meso -ovarium, of the side of the broad ligament, 
and of the suspensory ligament of the ovary. The tube gener- 



OVARIAN TUMORS. 



803 



ally remains separated by its mesosalpinx from the tumor, 
though the ampulla is often fastened to or approaches the 
tumor, because of the strongly drawn infundibular ovarian 
ligament, and the tube is usually elongated. In ovariotomy 
the tube is generally removed with the pedicle. After the 
removal of the tumor the cut surface presents a triangular 
appearance, in which the angles are pointed or blunt, small 
or large, and formed by the stump of the ovarian ligament, 
the transverse section of the tube, and the stump of the sper- 
matic artery. The pedicle consists of smooth muscle-fibers, 
connective tissue, and hypertrophied blood-vessels. 

The pedicle varies in length from four to twenty ^centimeters ; 




Fig. 513. — intraligamentar}' Ovarian Cyst. 



in breadth, from two to twelve centimeters; and may be en- 
tirely absent. The difference in the development of the pedicle 
is due, in part, to the insertion of the ovary upon the posterior 
surface of the broad ligament, and partly to the origin and 
gro^vth of the tumor. 

With the ovary originally embedded in the ligament, the 
development of the cyst in its external part will result in the 
formation of a pedicle; but the growth of the cyst toward the 
hilum may result in the spreading-out of the broad ligament 
and the formation of a subserous cyst. A cyst growing out- 
ward through the ligament may cause it to split and form two 
pedicles. As a tumor develops inw^ard in an embedded ovary, 
and spreads out the ligament, the uterus is pushed to one side, 



804 



GYNECOLOGY. 



and the tumor fills up the side of the pelvis, to displace the 
pelvic organs in general. Such a tumor becomes firmly fixed 
in the pelvis, pushes the peritoneum off from the uterus, in- 
vades the space between it and the bladder or rectum, and 
not infrequently partly spreads out the uterus upon its sur- 
face. Such growths are known as intraligamentary cysts. 
The cyst may be only partly subserous, having spread out 
the anterior wall of the broad ligament in advance of it, so 
that the inferior surface of the tumor is uncovered by the serous 
membrane. The separation of the posterior leaflet in such a 
growth reveals a long pedicle formed by the anterior fold. As 
an ovarian tumor develops, its increasing weight carries it 




Fig. 514. — Cyst Embedded in the Pelvis. 



backward into the retro-uterine pouch. It is very rarely found 
in front of the uterus. The subsequent development causes 
it gradually to fill the pelvis until its size no longer permits 
it to remain below the brim, when it rises into the abdomen. 
With the change of position there is a partial rotation of the 
pedicle, which is without clinical significance unless it exceeds 
a quarter of a circle. Occasionally, the withdrawal from the 
pelvis is retarded by a marked projection of the promontory 
of the sacrum, a roomy pelvis, or extensive adhesions. Such 
a tumor as it increases in size compresses the pelvic viscera, 
forces the uterus and bladder upward, and may dissect down- 
ward until it protrudes at the vagina, as in a case under my 



OVARIAN TUMORS. 



805 



observation, which was covered only by the posterior vaginal 
wall. 

The nonpedunculated tumor, as it progresses, becomes 
limited by the lateral walls of the pelvis, after it has spread 
out the structure and come in contact with the parametrium. 
In its further growth it is pushed upward and to the opposite 
side, carrying the uterus. These changes frequently displace 
the sigmoid portion of the colon, placing it above and in front 
of the tumor. The intestine is frequently compressed, but not 
sufficiently to close its canal, and the large vessels are often 
obstructed. 

The presence or absence of the pedicle depends somewhat 






p^^$^.Bi 







V.i' .' 



A".^ , 










Fig. 515. — Adenocystoma of Ovary, showing Papillary Formation. 
a. Papillary projections. 



Upon the variety of the cyst. The glandular incline to a long 
pedicle, the papillary to a short or absent pedicle, and the der- 
moid to a short, strong pedicle. 

625. Structure. — The consideration of the internal struc- 
ture of the glandular cysts justifies their division into areolar, 
unilocular, and multilocular. These glandular cysts, accord- 
ing to Virchow, originate in an invagination of the proliferating 
ovarian epithelium into the stroma. Further invagination 
and proliferation of the tissue result in the formation of new 
gland tubes, from which new cysts form. (Fig. 515.) The 
continuation of these processes results in the formation of the 



806 GYNECOLOGY. 

many-chambered glandular or adenomatous cyst. Mary A. 
Dixon-Jones attributes ovarian growths to inflammation through 
which the tissues become embryonal and new growths follow. 

Areolar Cyst. — A conglomeration of small cysts with a thick, 
well-developed, and vascular stroma is known as an areolar 
ovarian cyst. A number of these cysts may have ruptured 
to form a considerable sized one, or the tumor may consist of 
a very large number of small masses, none of which will exceed 
the size of a plum. (Fig. 516.) 

Unilocular cysts often attain an enormous size, but examina- 
tion discloses evidences of their previous division into numerous 
smaller cysts, so that we can safely assert that all unilocular 
cysts have originated from the multilocular. The investigation 




Fig. 516. — Areolar Ovarian Cyst. 

of a large cyst will usually show the presence of small cysts 
in its walls, and not infrequently the remains of septa within 
its cavity. 

Multilocular cysts contain a number of cysts of varying 
size, so arranged as to present the appearance of a single tumor. 
As these individual sacs increase, their intervening walls be- 
come gradually thinned, until, one after another, they rupture 
and the sacs coalesce to form larger single chambers. Not 
infrequently the circumference of the septa remains, to be- 
come still more stretched as the tumor grows, until it forms a 
cord-like thickening upon the inner surface. Occasionally, 
the vascular structure alone remains to indicate the former 
septum. In sudden rupture the vessels of the septa are torn. 



OVARIAN TUMORS. 



807 



producing extensive hemorrhage into the sac, which changes 
the character of the cyst-contents. 

In the principal cyst we usually find a wall of three layers, 
the outside consisting of pure connective tissue, like the al- 
buginea of the ovary. The middle layer consists of loose con- 
nective tissue with numerous large vessels, while the inner 
layer is rich with cells and contains numerous small vessels. 

The external surface of the cyst is covered with columnar 
epithelium, which differs from the pavement epithelium of the 
peritoneum. The cysts are lined with a one -layered cylindric 
epithelium, which presents different forms in different tumors, 
and by its structure governs the character of the secretion in 




Fig. 517. — Unilocular Cyst. 



the various sacs. It is only in the smaller sacs, however, that 
the true similarity of the epithelium and secretion is observed. 
In the larger cysts the epithelium undergoes degenerative 
changes; is flattened by pressure; suffers disturbances of nu- 
trition through thinning of the septal wall ; and undergoes fatty 
or albuminous changes, which cause the epithelium entirely 
to disappear from the wall of the larger cysts. Epithelial 
sprouts may remain upon the wall, forming new growths. 

Pfannenstiel directs attention to the possibility of the forma- 
tion of papillary growths in the adenomatous cysts. This 
formation is of great variety, and is found inside as well as upon 
the surface of the tumor. Sometimes these growths are but 



808 



GYNECOLOGY. 



Sparsely distributed upon the inner surface of a large cyst; in 
others they appear as circumscribed tufts upon one side, while 
the remaining portion is smooth; or, again, the entire cavity 
may be filled with strong, branching growths, while the quan- 
tity of fluid is very scanty. The larger the cyst, the greater 
the probability that a large portion of the wall is smooth. As 
a rule, the papilla are most marked upon the side of the cyst 
toward the hilum, while the peripheral side will be scantily, 
if at all, involved. 

A great variety in the quality of these vegetations exists; 
at times only small wart -like growths, from one to two milli- 
meters high, are scattered over the surface, together giving 

a velvety or grater-like 
appearance; at others, 
branching growths of 
various sizes, up to that 
of an apple, which may 
be either broad-based or 
with a thin pedicle. All 
the changes are present 
that are found in the 
ordinary papillary cyst. 
The growths appear 
either as reddish, granu- 
lating, cauliflower -like 
projections, or as sago- 
sized masses; rarely in 
the grape-cluster form. 
Cyst -contents often 
present very great con- 
trasts in their color and 
consistency ; they may 
be found almost color- 
less, straw-colored, green, purple, or black in color; thin or thick; 
viscid or gelatinous in consistency. The contents of the various 
cysts in the same tumor will differ in color and consistency. In 
some the fluid will be thin, and in others so viscid that it will not 
flow. The fluid in the smaller cysts is more consistent, and be- 
comes thinner as the cysts increase in size, because of changes 
in the epithelium. 

The special gravity of the fluid varies from 1002 to 1020, 
with an average of about 1012. However viscid the fluid, it is 
found absolutely structureless. Blood-corpuscles, epithelial cells, 
and crystals of cholesterin are often present. The reaction of the 
fluid is neutral or alkaline. Upon analysis various forms of 
albumin, as the met albumin, paralbumin, and albumin-peptone, 
are found. 




Fig. 518. — Multilocular Cyst. 



OVARIAN TUMORS. 



809 




Fig. 519. — Small Papillar}^ Ovarian Cyst. 



626. Papillary Proliferous Cysts.- — The papillary cysts show 
a marked proliferation of the connective tissue, which forms itself 
in tufts upon the inner surface of the tumor, as described in the 
complication of the 
glandular growths 
above. These 

branching projec- 
tions may distend 
the sac to bursting, 
and these tufts pro- 
ject upon the out- 
side, leading to 
rapid infection of 
the general perito- 
neum. The vegeta- 
tions spring up lux- 
uriantly over the 
surface of the ovary, 
are carried to every 
part of the perito- 
neal cavity, and not 
infrequently, by the 

action of the diaphragm, are carried to the upper surface of that 
muscle into the thorax. 

The contact of this infection with the peritoneum rapidly 

produces ascites. 
Similar vegetations 
may arise spontane- 
ously from the sur- 
face of the ovary, 
and are then known 
as superficial papil- 
lomata. It is prob- 
able that these . are 
cases in which a 
very small cyst has 
opened and afforded 
the seed which has 
infected the exter- 
nal surface. The 
papillary tumors 
rarely attain a large 
size, and are gener- 
ally bilateral. The dendritic grow^ths project in every direction, 
are reddish, or pearly white and glistening, often three or four 
inches long, and have the appearance of stems of coral. The 




Fig. 520. — Papillary Tufts upon Inner Wall of Cyst. 



810 GYNECOLOGY. 

masses have usually undergone a partial calcification, so that 
they break easily and without bleeding. 

627. Dermoid Cysts. — These are growths in which are found 
skin and mucous membrane, together with all the structures gen- 
erally associated with such tissues. The tissues most frequently 
found are hair, teeth, nails, and sebaceous and sweat glands. 
Other structures, occasionally seen, are the mammae, horn, bone, 
unstriped muscle-fiber, and, rarely, tissue resembling brain. Fat 
or sebaceous material exists in the largest quantity, often at the 
temperature of the body in a liquid state. Occasionally, it is 
found in solid balls. Sutton reports finding over three hundred 
of these in one sac. Hair is frequently present in great abun- 
dance, and varies in color, length, and quantity. The hair may 
be blond, brown, or black, but bears no relation to that of the 




Fig. 521. — -Surfaces of Ovaries Infected with Papillary Vegetations. 

individual. Teeth are found in about one -half the cysts; they 
may be loose, fixed, or buried in the wall. Section through the 
tooth often reveals it situated in a bony alveolus. Beneath the 
hard crust of the tooth is found a white or reddish-yellow medul- 
lary substance. 

We may occasionally find incisors, molars, and premolars in 
the same bone. The number of teeth is often enormous. Schna- 
bel described a case which had three pieces of bone and one 
hundred teeth. Plouquet found three hundred teeth. Various 
bones have been described, as, the jaw-bone, the petrous portion 
of the temporal bone, ribs, and the pelvic bones. A finger with 
articulated phalanges, nail, and nail fold, and an entire skeleton 
have been recognized. In a double dermoid removed from a girl 



OVARIAN TUMORS. 811 

of eleven years I found a Avell-formed half of the upper jaw, 
equipped with teeth, alveolar process, and normal mucous mem- 
brane. 

Dermoids do not always occur alone, but in conjunction with 
large glandular cysts, the dermoid forming but a small part of 
the mass. Sometimes the entire cyst Avill be found filled Avith 
sebaceous material, while careful examination, after washing, 
shows that the skin covers only a small part of the mass. 

Teratoma is a more complex form of tumor which is usually 
classed with the dermoid. It contains an even more varied 
structure, and resembles more the solid growi:hs than the cystic. 
It often attains an enormous size, and contains the various 
structures of the dermoid and cartilage and a large amount of 




%■■■• ") 



Fig. 522, — Dermoid Ovarian C3^st. 

connective tissue. Dermoid groAvths may appear at any age. 
They have been found in children at birth and in women of 
ninety years. 

The contents of a dermoid are exceedingly irritating, and 
every precaution should be practised to prevent the peritoneal 
cavity from being soiled. I saw a patient in whom an attempted 
aspiration resulted in drawing out a wisp of hair ; the patient at 
once developed peritonitis, which an early operation failed to 
prevent becoming fatal. 

628. Parovarian Cysts. — The parovarium is situated in the 
lateral part of the mesosalpinx, and is the remains of the sexual 
part of the Wolffian body. It resembles in its arrangement a 



812 GYNECOLOGY. 

comb, the back of which is directed toward the tube, while the 
teeth, some twelve to fifteen in number, converge toward the 
ovary. They are lined with large cylinder epithelium and ter- 
minate in blind extremities. The tumors which originate from 
this structure are almost always cystic and subserous, and con- 
sequently have a double wall. The external peritoneal one is 
easily separable. The pedicle consists of the tube and of the 
median ovarian and the suspensory ligaments. Torsion of the 
pedicle, when long, can easily occur. There are two kinds of 
cysts which arise from the parovarium, of which the most fre- 
quent are the small pedunculated, connected with Kobelt's 
tubules, which rarely become larger than a pea, and are of no 
clinical significance. The more important are the sessile, which 
remain between the folds of the broad ligament and burrow into 
it as they enlarge. These cysts are usually small, though Kum- 
mel describes one that weighed forty-two pounds. In the large 
cysts the tube becomes elongated. The contents of the cyst are 
clear and limpid, with a specific gravity of loio and an alkaline 
reaction. 

The parovarian and broad ligament cysts form about eleven 
per cent, of the abdominal tumors of pelvic origin, and both 
proliferating and. dermoid growths have been found in this 
situation. 

These cysts are distinguished from the ovarian, first, by the 
ease with which the peritoneum can be stripped off; second, by 
the ovary being generally found attached to the side of the cyst ; 
third, by the cyst being unilocular; fourth, by the Fallopian tube 
stretched over the cyst and never communicating with it; and, 
lastly, by the gradual thickening of the mesosalpinx. 

629. Solid Ovarian Tumors. — The solid growths of the ovary 
comprise five per cent, of the cases that present themselves for 
operation. These tumors are innocent and malignant, and may 
become cystic. 

630. Fibromyoma, the benign form, is a rare tumor, but is 
the most common species of solid ovarian tumor. It closely 
resembles the uterine fibroma, and is frequently accompanied by 
ascites. Its growth is slow, and the mass retains the normal 
shape of the ovary. Adhesions are rare; indeed, owing to the 
peritoneal fluid, the mobility is increased. Occasionally, we have 
a growth — the fibroma — in which the minute structure consists 
of wavy bundles of closely packed fibrous tissue intermixed with 
small round cells. Williams describes one of these that weighed 
seven pounds seven ounces; Doran, one of seventeen pounds. 
The myomatous variety is more frequent, and occasionally under- 
goes calcareous degeneration, when it may be mistaken for an 
osseous tumor. 



OVARIAN TUMORS. 



813 



An apparent hypertrophy, instead of atrophy, of the corpus 
luteum results in the formation of a growth, occasionally reac ing 
the size of a walnut, which Dr. Mary D. Jones pronounces a 
gyroma, and believes to be closely connected with the endothe- 
lium. It probably develops from the corpus luteum when in the 
cortex, and from the endothelium in the medulla. Leopold de- 
scribes a peculiar form of ovarian fibroma containing alveolar 
spaces packed with epithelioid cells. They are produced by 




Fig. 523. — Fibromyoma of Ovary, 



Fig. 524. — Sarcoma of the 
Ovary. 



dilatation of the lymphatic and capillary channels and the pro- 
liferation of their endothelium. 

631. Sarcoma of the Ovary. — Sarcoma resembles in form, size, 
and color the fibroid, excepting that its surface is smoother. Its 
consistence is softer than the fibroid, though it contains much 
fibrous tissue, which renders the diagnosis at times difficult to de- 
termine. Sarcomata occur as round-cell and spindle-cell growths ; 



814 GYNECOLOGY. 

when the latter predominate, the tumor is more soHd and more 
strongly resembles the fibroma. The muscle-fibers are longer 
and the nuclei are more slender and rod-like. The round-cell 
structure is softer, often presenting macroscopically medullary 
properties similar to those of medullary cancer, and under the 
microscope are found large layers and nests of round cells, united 
with irritation cells, and penetrated by numerous blood-vessels of 
every caliber. 

Spindle and round cells are frequently combined, while myx- 
omatous transformation exists in both kinds, but cartilage and 
bone formation rarely occurs. 

Combinations of sarcoma with adenoma are observed in the 
walls of the larger cysts, sometimes with sarcomatous degenera- 
tion of the stroma. In places, large alveoli are separated by 
vascular connective tissue, which contains large cells undergoing 
fatty degeneration and resembling carcinoma. This condition 
Spiegelberg has called sarcoma carcinomatosum. 

632. Carcinoma of the ovary is a much more frequent condi- 
tion than sarcoma. The medullary variety is the most common, 
and may form a tumor as large as a man's head. The disease 
occurs primarily, but much more frequently as a secondary 
manifestation. 

633. Endothelioma of the Ovary. — A growth is occasionally 
found in the ovary which originates from the endothelium of the 
lymph-spaces or blood-vessels of the organ. It has been pre- 
viously classed by pathologists with both sarcoma and carcinoma, 
resembling the sarcoma from its frequent metastasis through 
the blood-vessels, a carcinoma in consisting of nests of cells with 
a fine stroma. The growth rarely attains a great size, not larger 
than an orange or fist, forms a solid tumor, and is a rather firm 
whitish growth. This same structure not infrequently is found 
complicating the glandular proliferating cysts, and gives evidence 
that many of these tumors, if carefully investigated, would show 
the presence of malignant conditions. 

634. Etiology. — Very little is yet known as to the general 
cause of ovarian tumors. Three theories for their origin have 
been presented: (i) The Cohnheim theory, which attributed 
their growth to the retention of embryonic products; (2) the 
theory advanced by Mary A. Dixon- Jones, that they were always 
the result of previous cases of inflammation, and that the in- 
flammatory condition of the ovaries gave rise to embryonal 
tissue from which the growth subsequently developed; and (3) 
the theory of parthenogenesis, or the development of the non- 
fecundated ovum as the result of some irritation. The first and 
second theories are those which have the greatest number of 
advocates at the present day. According to the first, der- 



OVARIAN TUMORS. 815 

moids are derived from the infolding of the ectoderm in embryonic 
life, and these cells during subsequent irritation take on active 
growth and result in the formation of the various tissues found 
in a dermoid growth. It is claimed, however, by the advocates 
of the theory of parthenogenesis that there are some structures 
found in the dermoid ovary which would require the infolding 
of all of the layers of the blastoderm in order to complete their de- 
velopment. The advocates of the first theory, however, direct 
attention to the fact that striated muscle is never found in 
the dermoid cysts. The character of irritation which sets in mo- 
tion the development of these growths, whether mechanical or 
chemic, animate or inanimate, or whether it differs in the various 
kinds of tumors, is as yet unknown. The frequent occurrence in 
a cystadenoma of double-sided growth from the covering epithe- 
lium favors the belief in a chemic irritation which has proceeded 
by the way of the uterus and tubes. The theory of the para- 
sitic origin of tumors is as yet unproved, though the analogous 
course of tumor disease with infection has demonstrated that the 
development of various kinds of tumors in the different tissues 
of the body from metastatic deposits is of great interest. 

The susceptibility to the influence of tumor exciters greatly 
varies in different individuals ; heredity, acquired disposition, age, 
trauma, scar formation, and inflammation are important factors. 
Of the influence of heredity little is known, though the occurrence 
of ovarian cysts in several women of one family is quite frequent. 
The age has no especial significance as they occur in every 
period of life. The glandular cysts are more frequent between 
the thirtieth and fiftieth years. All varieties are less frequent in 
childhood and old age. Fetal tumors are rare, and generally 
consist of simple follicular cysts. These cysts increase in fre- 
quency as the child approaches puberty, probably then induced 
by the congestive hyperemia. 

Ovarian growths are more frequent in the single than in the 
married. Scanzoni indicates chlorosis as a predisposing factor, 
and Fenwick, tuberculosis ; but these are difficult to demonstrate. 

635. Natural Progress. — Proliferating cysts in the advanced 
stages grow more rapidly than either the dermoid or solid tumors, 
unless the latter are malignant. About the early stage of ovarian 
tumors but little is known, as they are usually well advanced 
before they come under the observation of the physician. The 
growth is probably slow. In dermoids and in benign solid tumors 
the growth throughout is slow. A rapid increase in the size of a 
gro-^^h, noticeable from day to day, is a symptom due to hemor- 
rhage. With the pelvic structures in a normal condition, the 
cystic ovary drops by its weight into Douglas' pouch, a little to 
one side of the median line. As it increases it advances in the 



816 GYNECOLOGY. 

direction of least resistance, which is upward, and pushes the in- 
testines before it, until it rises out of the pelvis and impinges 
against the abdominal wall, when it assumes a central position. 
The pedicle, at first anterior and inferior, is now directly beneath, 
and often becomes posterior. The tumor lies directly above the 
uterus, and, resting upon the brim of the pelvis, causes but little 
inconvenience. Occasionally, the tumor becomes impacted in 
the pelvis through irregularities in its growth or the formation 
of extensive adhesions. Sometimes the tumor pushes the broad 
ligament before it, or, when it develops in the hilum, it will 
spread out the ligament and become an intraligamentary growth. 
Once the growth rests upon the pelvis, in its further advance it 
pushes the intestines upward and laterally. If undisturbed, the 
enlargement becomes very great, the diaphragm is pushed up- 
ward, severe pressure symptoms follow, and the action of the 
heart and lungs is obstructed. The limbs appear as mere appen- 
dages to the enormous abdomen. The pressure affects the circu- 
lation, respiration, and digestion, and the renal secretion. There 
is marked suffering, emaciation, and the characteristic facial ex- 
pression known as facies ovariana. The presence of ovarian 
tumors does not interfere with ovulation and menstruation, even 
though both ovaries are involved, as long as any portion of the 
ovarian stroma is destroyed. Thornton reports a case of preg- 
nancy with bilateral dermoid disease. In solid tumors amenor- 
rhea is due to the total destruction of the Graafian follicles. 

636. Symptoms. — In their early stages ovarian tumors rarely 
produce any symptoms. Movable tumors generally come first to 
observation when they rise out of the pelvis. An apple-sized 
tumor will occasionally, though movable, cause unpleasant symp- 
toms, such as pain in the sacrum, which extends down the leg. 

Intraligamentary tumors or those prevented by adhesions 
from rising produce symptoms as soon as they fill the pelvis, 
especially by obstruction to defecation and micturition. As 
the tumor increases, the sensations of pressure and unpleasant- 
ness are aggravated. Besides the effects given in the descriptiont 
of the progress, the skin becomes stretched, forms striae, and 
swelling of the navel and hernia occur. More rarely, from the 
pressure upon the great vessels, there are edema and varicosities 
in the legs, sexual apparatus, and skin of the abdomen. 

Albuminuria is present, and diminution of the urine from 
compression of the renal veins is observed, which disappears 
with the removal of the pressure. Severe compression symptoms 
from the presence of very large tumors are now rarely seen. 

Uterine or vaginal prolapse sometimes complicates the condi- 
tion, but more frequently ascites and fluid collections follow the 
rupture of a cyst. 



OVARIAN TUMORS. 817 

Menstruation is usually unaffected, and sometimes continues 
regular when subsequent microscopic investigation has failed to 
show any functionally capable structure. Menstruation disap- 
pears comparatively early in those cases in which the follicles 
perish from the development of sarcoma or carcinoma, and in the 
papillary cystadenoma, when bilateral. In contrast to fibroid 
tumor, the menstruation decreases, and a disposition to the 
menopause is betrayed, not from absent ovulation, but as the 
result of constitutional conditions. Amenorrhea may exist for 
several years and menstruation may return after the removal of 
an ovarian cyst. In intraligamentary growths, especially the 
papillary cystadenoma, severe menorrhagia occurs from pressure 
upon the uterine veins. 

637. Complications. — x^scites occurs infrequently with cystic 
growths, unless from rupture, but is very frequent in the solid 
tumors. The cause is unknown. It can arise from pressure 
upon the venae cavae and large abdominal veins. Edema may 
involve one or both legs. Distention occurs in the ureter and 
pelvis of the kidney. The most frequent complication is the 
formation of adhesions between the surface of the tumor and the 
omentum, the intestines, the uterus, the bladder, and the abdom- 
inal wall. These adhesions arise from inflammation, peritonitis, 
and sometimes painlessly. They possibly arise from the loss of 
surface epithelium of the cyst, through friction; fibrinous exuda- 
tion results, and the formation of adhesions between adjacent 
surfaces. The adhesions become firm, dense, often thread-like, 
and between the omentum and the growth may convey vessels 
of sufflcient size to be an important factor in the blood-supply. 
Dermoids are frequently complicated by adhesions. When 
adhesions occur between the tumor and the bladder or the in- 
testine, the cyst may open into either, and thus discharge its 
contents. A lock of hair may project from a dermoid into the 
rectum or the bladder. Adhesions are of importance from the 
increased difficulty in the removal of the growth. It is fre- 
quently exceedingly difficult to distinguish the cyst -wall from the 
parietal peritoneum. 

Torsion of the Pedicle. — ^A moderate twisting of the pedicle to 
90 degrees produces no symptoms ; it is only when the torsion is 
sufficient to influence the circulation, or above i8o degrees, that 
disturbance is occasioned. A slight twisting always occurs with 
the elevation of the cyst from the pelvis. The right-sided tumor 
turns to the left, and the left-sided to the right. The cause of the 
torsion is unknown. Kiistner ascribed it to peristalsis and the 
changes from the distention of the rectum ; Carlo, to sudden belly 
pressure; Mickwitz, to contraction of the transversalis muscle. 
The influence of pregnancy and changes of position in a relaxed 



818 



GYNECOLOGY. 



abdomen which contains a tumor with a long pedicle are factors. 
This torsion may readily arise from manipulation to determine 
the diagnosis. I saw it occur in a young girl who had been 
thrown upon the floor by her companion, who sat upon her abdo- 
men. The torsion can occur with very small tumors which are 
still within the pelvis, in which it most probably arises from the 




Fi 



g- 525- 



-Torsion of the Pedicle. 



varying distention of the bladder and rectum. The twist may 
involve but one or two turns of the pedicle, though as many as 
six twists have been observed. The tube usually shares in the 
twisting, and torsion of the uterus has infrequently occurred. 
Torsion of the pedicle can take place in any variety of tumor, 
though from its greater frequency it is found most often in the 



OVARIAN TUMORS. 819 

cystadenoma. Dermoids and parovarian growths also show a 
marked tendency to undergo pedicle-torsion. The tendency to 
torsion of the pedicle is favored by the existence of a long, mem- 
branous pedicle, a spheric form of the tumor, and a smooth sur- 
face. The twisting is still further favored by pregnancy, labor, 
and child-bed, through the changing relations of the organs in 
the abdominal cavity. 

The results of the torsion are dependent upon the rapidity 
with which it has occurred. The torsion causes obstruction of 
the vessels, in which the thin-walled veins suffer before the more 
resistant arteries. There necessarily results an increased engorge- 
ment of the blood in the tumor. Solid tumors are completely 
penetrated by blood, and cystic growths undergo hemorrhagic 
infiltration of the walls as well as of the contents. The surface 
presents a black, blue, or dirty brown color, the cyst rapidly 
increases in volume, and, as a result, easily breaks down. A fatal 
result can occur from hemorrhage into the abdominal cavity. 
More frequently hemorrhage is arrested, but the nutrition of the 
tumor suffers. The covering epithelium is lost, and extensive 
adhesions occur between the surface of the tumor and the sur- 
rounding structures, as the omentum, intestines, and parietal 
peritoneum. 

These adhesions are, at first, very loose, then become organ- 
ized, and the growth thereby obtains a new source of nutrition, 
by which it maintains its size or proceeds to new gro\Ai:h. Further 
twisting leads to obstruction of the arteries, which is followed by 
necrosis of the growth. Necrosis is followed by shrinking of the 
tumor from the absorption of its fatty constituents, though it 
rarely disappears. It can become calcified. Peritonitis, with the 
formation of extensive ascites, almost always results. The peri- 
tonitis arises independent of micro-organisms, and is due to the 
irritation from the presence of a foreign body or to the chemic 
products of the tumor. An infection can occur through the tube 
or from kinking of the intestine. Sometimes suppuration of the 
tumor and pyemia ensue. A slight torsion can bring about 
edema instead of hemorrhage, and ascites instead of peritonitis. 
The pedicle may be found attenuated or its thickness may be 
doubled. The dermoid growths are sometimes found free in the 
abdominal cavity or in pedicle-like adhesion with other structures. 
A dermoid under my observation was held in front of the uterus 
by adhesions above to the omentum, and below to the perito- 
neum ; the tube and upper part of the broad ligament upon the 
left side had entirely disappeared. The separation was evidently 
old, for the wall of the growth had undergone calcareous degen- 
eration. Ileus has resulted from the adhesion of a loop of intes- 
tine to the tumor or to its pedicle. 



820 



GYNECOLOGY. 



/ 



Symptoms. — Not infrequently there are no symptoms of tor- 
sion. Such cases are usually recent or the torsion has been 
slight. It may be suspected when the patient is taken with 
severe pain in the belly, associated with meteorism, and sensi- 
bility to pressure, acceleration of the pulse, sometimes also sin- 
gultus, vomiting, and fever. In torsion of high degree indications 
of intra-abdominal bleeding appear, with not infrequently marked 
collapse. In the chronic condition the pain and unfavorable 
symptoms are more gradual, though many patients are bedridden 
and show a distinct loss of strength, occasioned by the absorption 
of the altered constituents of the tumors producing a condition 
resembling cachexia. 

Inflammation and Suppuration of the Cyst. — Cysts can undergo 

inflammatory and 
/, ,£L suppurative changes, 

5 I though much less fre- 

. quently than f ormer- 

/ / ly, as puncture of the 

\ cyst is not so often 
• practised. In some 
tumors, the contents 
of which resemble 
pus, the microscope 
demonstrates that 
the material consists 
of epithelium and cell 
detritus, but not of 
leukocytes. The in- 
flammation is mostly 
communicated by the 
tube and intestine ; 
the latter especially 
when adhesions have 
taken place between 
the intestine and the 
sac. The opportuni- 
ties for infection are increased by parturition and the puerperium, 
as a result of the possible trauma occasioned during the labor. 
Dermoid tumors are inclined to suppuration, formerly supposed 
to be due to the peculiar pus-exciting character of their contents, 
but much more probably the result of injury which the tumor 
has undergone during its long retention within the body. We 
have already seen that the dermoid was prone to torsion of its 
pedicle, and its contents are an excellent culture- medium for the 
propagation of bacteria. 

Symptoms. — The occurrence of inflammation and suppuration 



I 



Fig. 526. — Dermoid Which Had Lost Its Original 
Relations and Was Nourished by Adhesions 
from the Omentum. 



OVARIAN TUMORS. 821 

is characterized by fever and typhoid phenomena, which vary in 
intensity according to the nature of the infection. The patient 
does not experience much pain unless peritonitis is associated. 
The pulse becomes very rapid and emaciation is progressive. 
Adhesions to the suppurating tumor occur, and the pus makes 
its exit, as in ovarian abscess, into the bladder, the rectum, or the 
vagina. It is but rarely that the pus is completely evacuated 
and that spontaneous recovery results. Death usually follows 
from pyemia. A rupture into the peritoneal cavity is quickly 
followed by fatal peritonitis. The evacuation of such a tumor 
through the bladder produces the greatest distress, as hair, teeth, 
and pieces of bone are discharged, sloughs become impacted in 
the urethra and induce cystitis, and there is retention of urine 
and marked vesical tenesmus. Fragments which remain in the 
bladder are coated over with urine salts, and become the nuclei 
of calculi. 

Rupture of Cystic Tumors. — Rupture of a cyst may occur sud- 
denly, the result of a fall or blow, or can gradually result from 
changes in the cyst-wall. It occasionally follows from internal 
pressure caused by the growth of the tumor. The latter accident 
produces no symptoms, and it is only exceptionally that hemor- 
rhage complicates spontaneous rupture. In papillary growths 
the pressure of the vegetations causes thinning of the cyst wall, 
and, finally, rupture ; or the growths project through the wall of 
the cyst, to extend over its external surface. Rupture of a cyst 
can occur into the surrounding viscera, but more frequently into 
the peritoneal cavity. In very thin- walled cysts this rupture 
occurs easily. Manipulation to determine the diagnosis, changing 
the position in bed, the act of coition, vomiting, may produce it, 
and frequently it occurs without assignable cause. The influence 
of the accident will naturally depend upon the character of the 
cyst-contents. Often, in the unilocular cysts, rupture into the 
peritoneal cavity is attended with no untoward symptoms, be- 
yond an excessive flow of pale urine. The patient will often pass 
several gallons of urine in twenty-four hours, and the abdomen, 
which was large, will become flattened, flabby, and readily permit 
the residual sac to be recognized by palpation. In single and 
parovarian cysts recovery can occasionally follow the rupture. 
Generally, the opening is closed by adhesions, and the fluid re- 
accumulates. In some cases the accident is followed by high 
temperature, rapid pulse, vomiting, pressure at stool, and diar- 
rhea, which indicate the absorption of the contents, and by a kind 
of auto-intoxication. In multilocular and dermoid growths the 
rupture into the peritoneal cavity is ordinarily followed by in- 
fection, a rapidly developing peritonitis, and, finally, death. Such 
a termination is probable not only in dermoid, but also in those 



822 GYNECOLOGY. 

cysts containing colloid material and pus. In the papillary cysts 
rupture results in the infection of the peritoneum, the formation 
of ascites, and the development of vegetations over the entire 
cavity. Sometimes an artery is torn in the rupture, and marked 
hemorrhage, with profound anemia, follows. Profound collapse 
has been noted. 

The occurrence of rupture is recognized by the disappearance 
of, or diminution in the size of, the tumor, the recognition of free 
fluid in the peritoneal cavity, peritonitis, collapse, diarrhea, and 
diuresis. The accident can be mistaken for torsion. Rupture 
into the intestine is evident from the character of the discharges ; 
when a profuse watery discharge escapes from the bowel rupture 
into the intestinal canal is suspected. External rupture is usu- 
ally easily recognized. When the discharge is pus or ichorous 
material alone, it is often difficult to determine whether it is 
from a cyst or an abscess in the walls. 

Complication of Ovarian Tumor with Pregnancy. — The exis- 
tence of ovarian growths does not preclude the occurrence of 
pregnancy, though their coexistence is comparatively rare. It is 
more frequent in the one-sided, though it occurs sufficiently often 
in double-sided disease to demonstrate its possibility as long 
as any functionating portion of ovary remains. The complica- 
tion can occur with any variety of ovarian tumor, though it 
is more likely to complicate the slow-growing forms — the dermoid 
and the pseudomucin — than the others. Numerous cases are 
recorded in which the patient carrying an ovarian tumor has 
successfully run the gauntlet of several pregnancies. The exis- 
tence of such a tumor, however, does increase the distressing 
symptoms and the danger of pregnancy. There is not the same 
tendency to rapid growth of the cyst during pregnancy as exists 
when a fibroid growth is complicated by the same condition. 
The assertion that the occurrence of pregnancy favors malignant 
degeneration in the cyst is unproved. The occurrence of carci- 
noma in a cyst during pregnancy is no proof that it was not pre- 
viously there, or that it would not have occurred had pregnancy 
never existed. The changing relations of pregnancy, labor, and 
childbed undoubtedly do favor the occurrence of torsion of the 
pedicle, and the delivery of the fetus, whether naturally or by 
the use of instruments, not infrequently crushes or bruises the 
cyst so that it ruptures or undergoes inflammation and suppura- 
tion. While the varying relations of pregnancy, labor, and the 
puerperium exert an injurious influence upon the progress of the 
tumor, it can, on the contrary, greatly disturb these processes. 
The diminished space in the abdomen affords less room for the 
normal development and increases the danger of abortion and 
premature delivery. Abortion has been frequently reported as a 



OVARIAN TUMORS. 



823 



result of the retroflexion of the uterus produced by the turaor. 
In labor a large tumor can materially interfere with the normal 
forces of delivery by decreasing the activity of the contractions 
and by altering the situation of the uterus. Much more worthy 
of consideration is the situation of a tumor of small size in the 
pelvis, below the uterus, where it acts as an obstruction to the 
progress of the child's head. If these are not flattened or pulled 
out of the pelvis, the head of the child can not enter, and, unless 
otherwise alleviated, 
labor may terminate in 
rupture of the uterus, 
tearing of the vagina, 
or bursting of the cyst. 
Such complications are 
necessarily attended 
with danger. The 
puerperium can be 
complicated by gan- 
grenous processes in 
the tumor and its 
pedicle, following the 
injury of labor. 

The coexistence of 
the ovarian tumor 
with pregnancy, when 
large, causes increased 
difficulty in respira- 
tion, through pressure 
upon the diaphragm, 
and can cause danger 
to life by the pressure 
and the tendency to 
albuminuria and ede- 
ma. The tendency to 
torsion of the pedicle, 
to rupture of the sac, 
and to subsequent in- 
flammation naturally 
clouds the prognosis. 

When the cyst is situated in advance of the uterus, an efl:ort 
should be made to push it up, and, upon failure, we may be left 
to the choice between delivery of the growth through a vaginal 
incision or its puncture through that canal and its removal after 
delivery. In the early months of the pregnancy operative inter- 
ference for the removal of the tumor has but little influence upon 
the progress of the pregnancy, and should be considered when- 




Fii 



:• 527 



An Ovarian Cyst beneath a Pregnant 
Uterus. 



824 GYNECOLOGY. 

ever the size and situation of the growth threaten the successful 
termination of the pregnancy. 

638. Degenerative Changes in the Cyst-walls. — The cyst-walls 
can undergo the following degenerative processes : 

First, calcification, which most frequently occurs in the inner 
layer of the main cyst-wall in the form of small granules or 
plates of lime, or the formation of psammous bodies similar to 
those seen in the papillary cysts. The calcification is increased 
with the impairment of nutrition following gradual torsion. In 
a case of dermoid which came under my observation the deposit 
was so extensive that the tumor resembled a calcareous fibroid. 

Second, fatty degeneration occurs in the papillary cells and in 
the connective tissue of walls of the cyst. This process is en- 
hanced by impairment of nutrition. The change in the septa of 
cysts occurs from the pressure of their contents, and ends in their 
partial or complete destruction. The presence of a large amount 
of fat in the walls is an evidence of slow growth. 

Third, atheromatous changes, which generally occur in the 
inner layer of the wall. 

Fourth, changes due to infarctions, which are indicated by 
whitish, opaque bodies found in the septa and surrounded by a 
red zone. 

639. Diagnosis.— In the diagnosis of ovarian tumors the 
physical signs are ascertained by the employment of inspection, 
palpation, percussion, and auscultation. The information de- 
rived by these procedures has been given. (Sections 97 to loi.) 
The difficulty in the diagnosis will depend upon the size, situ- 
ation, relation, and complications of the tumor. 

The questions to be considered are: (i) Is the abdominal 
enlargement under observation a tumor ? (2) The existence of a 
tumor recognized, is it an ovarian growth? (3) An ovarian 
tumor admitted, its relations to the surrounding parts and the 
existence or absence of a pedicle or of adhesions remain to be 
determined. (4) The variety of the ovarian tumor. 

First, Is the distention of the abdomen an intra-abdominal tumor f 
This, at first thought, may seem an unnecessary question, but the 
frequency with which various enlargements of the abdomen are 
mistaken for such growths, and the occasional difficulty in 
arriving at a certain determination, fully justify the careful con- 
sideration of the subject. For convenience of study we divide the 
ovarian growths into small, or those situated within the pelvis, 
and large, when they are resting upon the pelvic brim. 

The abdominal enlargements, other than tumors, with which 
an ovarian tumor can be confused are obesity, desmoid tumor of 
the abdominal walls, ventral hernia, tympanites, fecal accumula- 
tion, distended bladder, ascites, and localized peritoneal effusion. 



OVARIAN TUMORS. 



825 



Obesity. — A large, pendulous abdomen, from the accumulation 
of fat within its walls or in the omentum, is sometimes mistaken 
for an ovarian tumor. The history of its development and the 
distribution of adipose tissue to other parts of the body, con- 
trasted with the general emaciation of an ovarian cyst, should 
assist in determining the diagnosis. The thickness of the fat 
accumulation can be pretty accurately estimated by grasping a 
fold of the skin and subcutaneous tissue between the thumb and 
fingers. 

Desmoid Tumor of 
the Abdominal Walls. — 
This growth, which is 
infrequent, develops in 
the muscle- wall, and 
partakes of the nature 
of a fibroid. Generally, 
from its weight it forms 
a dependent tumor, 
which sometimes ex- 
tends to the knees. It 
is quite movable with 
the abdominal wall, and 
is superficial and very 
hard. Its situation in 
the wall, covered by 
the skin and superficial 
fascia, and the deter- 
mination by vaginal or 
rectal examination of 
the absence of any con- 
nection with the pelvic 
viscera, determine its 
character. 

Ventral Hernia. — - 
Twice in diastasis of 
the recti muscles with 
a large protrusion of 
the viscera have I been 
called a long distance 

to operate for supposed ovarian cyst. Palpation of the intestinal 
coils, the resonance upon percussion, and the observation of the 
peristalsis, readily seen through the thin covering of skin and 
peritoneum, should have excluded the diagnosis of a cyst. 

Tympanites. — A localized tympanites or phantom tumor, a 
condition similar to pseudocyesis, is sometimes mistaken for an 
ovarian cyst. The loud volume of resonance obtained by per- 




Fig. 528.- 



-Desmoid Tumor 
Wall. 



of Abdominal 



826 GYNECOLOGY. 

cussion should be considered as contraindicating the probabihty 
of the existence of a cyst. It is true that in rare instances a 
communication of a cyst with the bowel will permit it to become 
resonant. A similar condition will arise from decomposition of 
cyst-contents, by which gas forms in the cavity. Even in these 
cases a sense of fluctuation can be secured, which is absent in 
the phantom tumor. The latter tumor will entirely disappear 
while the patient is under an anesthetic, to return as soon as the 
patient recovers. 

Fecal Accumulation. — An accumulation of feces is sometimes 
called a fecal tumor. It forms in the colon, and when in the 
transverse portion of the gut, may descend and lie directly over 
the pelvis. These accumulations are occasionally quite exten- 
sive, but are recognizable by their length, by the peculiar sensa- 
tion under palpation, and by the possibility of leaving an imprint 
upon pressure, but most of all by the fact that they disappear 
under the administration of purgatives and enemata. 

Distended Bladder. — A distended bladder forms a tumor in 
the lower part of the abdomen which fluctuates and may very 
readily be mistaken for an ovarian cyst. This suspicion is 
apparently confirmed by the information that the patient is con- 
stantly passing urine. The fixed position, and the bulging of 
the anterior wall of the vagina, should be sufficient to indicate 
the use of a catheter, when the tumor will disappear. It should 
be the invariable rule to empty the bowel and bladder preliminary 
to the examination of an abdominal tumor. 

In pregnancy, fibroid tumor, or even a simple ovarian tumor 
impacted in the pelvis, the urethra may be so distorted and 
compressed as to render necessary the use of a soft male catheter. 

Ascites. — In uncomplicated ovarian cysts the differential diag- 
nosis from ascites is not dihicult to make. The cysts have, in 
common with ascites, enlargement of the abdomen, fluctuation, 
and the symptoms arising from pressure against the diaphragm. 
Not infrequently both conditions will be characterized by pro- 
gressive loss of strength and flesh and by more or less edema of 
other parts of the body, but there is a marked difference in the 
manifestation of these symptoms when we come to analyze them. 
The enlarged abdomen in ascites is more or less flattened and its 
widest diameter is transverse, while the ovarian cyst is most 
prominent in the vertical diameter and is narrow from side to 
side. Fluctuation is very distinct over the abdomen in ascites 
and in unilocular cysts, but the wave of fluctuation will be found 
to extend nearer to the vertebra in the former. In the well-filled 
cyst the projection of the vertebras prevents the approach of the 
fluid to the lumbar regions. In multilocular cysts the wave of 
fluctuation is more broken, and frequently is only recognized as 



OVARIAN TUMORS. 



827 



a sensation of elasticity. The loss of strength is often more 
marked in ascites, while the appearance of emaciation is greater 
in the cyst. In renal and cardiac dropsy there is much greater 
disposition to anasarca. In a very advanced and large ovarian 
tumor the pressure may induce considerable dropsy of the 





NTESTINAL ^^^^ 
:oj:-r±_^ RESONANCE-- -lao'?^\ 



Fig. 529. — Relative Zones of Dullness and Resonance in Ascites. 



extremities, but the abdominal distention is in much greater 
proportion. 

On palpation the ovarian tumor presents greater resistance 
and can frequently be outlined and its surfaces distinctly deter- 



828 



GYNECOLOGY. 



mined. The abdominal surface can be moved over the tumor 
and the upper margin is easily recognized. The existence of 
adhesions or the presence of a large quantity of fluid may obscure 
the conditions. Percussion affords the most valuable informa- 
tion. In ascites there is a distinct zone of resonance over the 



iiii-r^^C^ 



/ — ~ DULNESJ OVER Q' ST 



%,< 




Fig- 530. — Relative Zones of Dullness and Resonance in Ovarian Cyst. 



center of the abdomen, or the point of greatest prominence, while 
the more dependent portions are dull. The zone of resonance 
changes with the position of the patient. In ovarian cyst, on 
the contrary, there is dullness upon percussion over the whole 



OVARIAN TUMORS. 829 

surface of the tumor, and resonance only after we have passed 
beyond its hmits, which is unchanged by position. As the tumor, 
in its growth, presses the intestines upward and to the opposite 
side before it, the resonance will generally be discovered above, 
and on the side opposite to that upon which the tumor has 
originated. Occasionally, in a distended colon, resonance may be 
secured over it in ascites. When the abdomen is very greatly 
distended, or when inflammatory conditions bind dowm the in- 
testines, resonance will be absent upon superficial percussion, but 
may be easily determined when more pressure is used. The pres- 
sure displaces the intervening layer of fluid and permits resonance 
to be obtained. In tubercular peritonitis and in hepatic dropsy, 
when the mesentery has undergone contraction and the peri- 
toneum is very much thickened, the diagnosis can be so obscure 
as to require an abdominal incision to determine it. 

Ascites may complicate an ovarian cyst, when, by displace- 
ment of a layer of fluid, the hand will come in contact with the 
cyst. The amount of resistance will aft'ord information as to 
whether the tumor is solid or cystic. The complication of ascites 
can be regarded as an evidence of malignancy or of some degen- 
erative process. The greater the amount of ascites, the more 
probable the malignancy. I have, however, seen very large 
ascitic accumulations from necrosis of a cyst after torsion of its 
pedicle. The uterus is freely movable in ascites, while in ovarian 
cyst it is but slightly movable, and displaced either downward 
and backward or upward and forward. In ascites arising from 
ruptured papillary c^^sts a dense, thickened mass is recognized 
upon each side of the uterus, which should cause a suspicion of 
its true character. 

Localized Peritoneal Effusion. — Localized collections within 
the abdominal cavity offer great difficulties in determining the 
diagnosis. Such accumulations are generally the result of tuber- 
cular disease, and the history of the development of the disorder, 
the general condition of the patient, and careful investigation of 
the abdomen will aff'ord an intimation as to its character. It 
was my misfortune recently to mistake a collection within the 
lesser peritoneal cavity for an ovarian cyst. The abdomen pre- 
sented the characteristic appearance of a large ovarian cyst. A 
vaginal examination Avould have revealed the uterus and ovaries 
below a collection which did not dip into the pelvis, but, unfor- 
tunately, no such investigation was made. The diagnosis of 
ovarian growth was accepted upon the external appearance. 
Upon abdominal incision the general peritoneal cavity was free 
from fluid. An apparent cyst upon which the intestines were 
spread projected into the incision, from which over three gallons 



830 



GYNECOLOGY. 



of straw-colored fluid were withdrawn, and investigation demon- 
strated the character of the cavity. 

Second, Is the tumor under observation an ovarian tumor f The 
physical signs vary with the size and situation of the tumor. In 
the early stage the tumor is entirely within the pelvis, and its 
position varies. When it reaches the size of a hen's egg, the 
tumor falls into the pelvis, where it remains until it becomes 
too large to be longer accommodated in that situation. Its 
relation to the corresponding side of the uterus permits its 
character to be determined by conjoined manipulation. When 
the growth has been complicated by peritonitis, the diagnosis may 




Fig. 531. — Hegar's Method of Determining Relation of Tumor to the Uterus. 



be difficult. Small tumors usually feel firm because they are not 
sufficiently large to afford fluctuation, or even elasticity. The 
latter is of importance, and is generally absent in proliferating 
cystomata, in dermoids, and even in small single cysts. When 
we are unable to separate the tumor from the uterus, and conse- 
quently to determine the existence of a pedicle, the latter can be 
ascertained by Hegar's method. This, while the patient lies upon 
her back, consists in seizing the uterus with a vulsellum, and 
dragging it well down, while two fingers in the rectum follow its 
borders to determine its relation to the growth, or the hand over 
the abdomen can depress the fundus and thus recognize its rela- 



OVARIAN TUMORS. 831 

tion. When a tumor is not large, it can usually be outlined by 
a hand over the abdomen and a finger in the rectum. The great- 
est difficulty is experienced when the tumor is complicated by in- 
flammatory conditions, is fixed, and often incarcerated. Tumors 
which have originated in the broad ligament, and which lie in 
close relation to the uterus, are usually less spheric and circum- 
scribed, and are less movable from their first inception. Fibroid 
tumors of the uterus and inflammatory growths of the tubes are 
likely to be confused with small ovarian cysts. These growths 
are pyosalpinx, hydrosalpinx, and hematosalpinx. The acute 
history, marked tenderness, evidence of inflammatory exudation, 
thickening, and matting together of the pelvic tissues, associated 
with marked pain, should distinguish the pyosalpinx. In hydro- 
salpinx the tumor can be movable, and may give a sensation of 
elasticity or fluctuation, but is oblong or gourd-like, rather than 
spheric. It is frequently closely adherent to the uterus, and 
affords a history of previous inflammation. A hematosalpinx is 
at first soft, then becomes hard from the coagulation of the blood. 
They are usually situated to one side of the pelvis and posterior 
to the uterus. Fibroid growths are firmer, and are closel}^ 
attached to the uterus. 

Large or Abdominal Growths. — A large ovarian cyst distends 
the abdomen, particularly at its lower part, rises abruptly from 
the pubes, and is sharply defined and generally symmetrically 
developed. Its outline, extent, and size are readily determined 
by palpation. In a large single cyst the surface will be smooth 
and regular, while in the multilocular cysts projections and irreg- 
ularities are often found. If it is made up of a large number of 
small cysts, it will be more resistant, although it will still present 
a sensation of elasticity. These growths are confounded with 
pregnancy, hydramnios, extra-uterine gestation, uterine myo- 
mata, retroperitoneal growths, and the tumors of the various 
viscera of the abdominal cavity. 

Pregnancy. — The enlargement of the abdomen is more rapid 
than in ovarian tumor. It is generally associated with sup- 
pression of the menses and with the presence of such sympathetic 
nervous phenomena as nausea, vomiting, disturbed appetite, and, 
in the more advanced stage, a florid, healthy appearance of the 
patient. Suppression of the menses is not a constant symptom 
of pregnancy, for there are some women who continue to men- 
struate during the entire pregnancy, nor is amenorrhea always 
absent in ovarian growths. Error is more likely to occur in the 
unmarried, during the early stage of pregnancy. The physician 
should refrain from making a diagnosis until he has had an 
opportunity to make a careful examination, and then should 
hesitate to express an opinion when there is the least reason for 



832 GYNECOLOGY. 

doubt. An examination a few weeks later will dispel the uncer- 
tainty. There is an absence of fluctuation in pregnancy ; but it 
is also absent in cysts with thick, viscid contents, or in the areolar 
and glandular varieties, which are made up of a large number of 
small cysts. As pregnancy advances, the fetal movements, 
heart-sounds, and parts of the fetus are recognizable. The heart- 
sounds are pathognomonic of pregnancy, but are not always 
heard, owing to the position of the fetus, the large quantity of 
fluid, or to fetal death. The conjoined manipulation will afford 
information as to the relation of the enlargement to the uterus. 
Gestation in one hora of a bicornate uterus can make the diagnosis 
difficult, but a careful bimanual exploration will demonstrate the 
association of the enlargement with the uterus, and the small 
undeveloped cornu in association with the enlargement. Under 
no circumstances should the size of the uterus be determined with 
a probe when there is the least suspicion of pregnancy. 

Hydrmnnios . — Hydramnios is a pathologic form of pregnancy 
in which there is a more or less large collection of amniotic fluid 
in the uterine cavity. Cases in which the collection exceeds 
two quarts have been mistaken for ovarian cysts. In large 
collections the abdominal cavity becomes greatly distended; 
its surface is smooth, white, and glistening, and fluctuation 
is very distinct. The patient suffers all the discomfort char- 
acteristic of a large cyst. The history will prove of value in 
determining the diagnosis. Hydramnios generally occurs sud- 
denly, and makes its appearance about the sixth or seventh 
month of a pregnancy which has previously run a normal course. 
Such symptoms could arise only from an ovarian cyst which 
had undergone some marked change in its nutrition, but this 
diagnosis would be excluded by the previous indications of 
pregnancy. The physical examination of such a patient will 
disclose an enlarged uterus, the cervix of which is frequently 
obliterated, os open, and covered with a dense membrane, 
through which, by manipulation, we are often able to distinguish 
parts of the fetus or obtain ballottement. Rupture of the 
membrane is followed by the discharge of a large quantity 
of water and the evacuation of the uterine contents. It should 
not be overlooked that the existence of an ovarian cyst does 
not preclude the occurrence of pregnancy, and the presence 
of the latter, by the increased flow of blood to the pelvis, may 
facilitate the growth of the cyst. As we have already seen, the 
rapidity of the growth may be so great as to require early inter- 
ference in order to save the life of the patient. Careful ex- 
amination will usually disclose an enlarged uterus either in 
front of or behind the cyst. 

Kxtra-uterine Pregnancy. — An ectopic gestation which has 



OVARIAN TUMORS. 833 

attained a size sufficient to permit it to be confused with an 
ovarian cyst will have presented the symptoms of early preg- 
nancy, possibly indications of rupture of the sac and internal 
hemorrhage. Later, the tumor may be found to one side of 
or behind the uterus, and so closely adherent to it as to render 
the differentiation from it exceedingly difficult. In advanced 
stages the fetal movements and the heart-sounds may be heard. 
Vaginal palpation will disclose the fetal parts covered with 
a thin wall. After the death of the fetus other changes occur 
which render the diagnosis still more difficult. The fetus 
shrinks, becomes macerated, and the decomposition produces 
an accumulation of gas, which, with the distinct fluctuation, 
makes the condition doubly obscure. A careful analysis of 
the subjective symptoms, associated with a thorough examina- 
tion, will generally permit its recognition. 

Uterine Myomata. — Generally, the slow growth, the re- 
sistance of the tumor, and the usual presence of multiple growths, 
their irregular contour, and their demonstrable relation to 
the uterus, should afford confirmation of the diagnosis. A 
tumor which has but recently come under the observation 
of the patient, and which has, through degenerative or ob- 
structive processes, taken upon itself rapid growth, miay afford 
considerable difficulty in ascertaining its true character. The 
difficulty becomes very great in edematous fibroids and in 
fibrocystic tumors. It would seem that the demonstration 
of the continuation of the mass with the cervix would be suffi- 
cient to demonstrate the uterine origin. Double ovarian cysts, 
particularly when the pedicle is short or absent, may so drag 
upon the fundus uteri as to make it apparent that the growths 
are a part of the uterus. The relation of the uterus to the 
tumor is best determined by grasping the cervix with a vul- 
sellum, which is held by an assistant; a second assistant draws 
up the tumor through the abdominal walls, while the principal, 
with one or two fingers in the rectum, and the hand over the 
abdomen, seeks the pedicle and ascertains its relation to the 
uterus. This procedure, even in double growths, will permit 
the fundus to be recognized and the nonuterine character of 
the growths to become known. In the early history of ab- 
dominal work not infrequently the abdomen was opened for 
an ovariotomy and a uterine fibroid was discovered. Indeed, 
the earlier removals of the uterus were cases of mistaken diag- 
nosis. Uterine myomata may complicate the presence of an 
ovarian cyst, and the consequent distention of the abdomen 
from the presence of two large tumors may render earlier inter- 
ference desirable. The ovarian cyst may be situated in front 

53 



834 GYNECOLOGY. 

of the myomatous uterus, and the growth may be unsuspected 
until discovered during the progress of an operation. 

Retroperitoneal Tumors. — Retroperitoneal tumors are very 
rare. They may originate from the tissue in the pelvis or from 
that of the subperitoneal portion of the abdomen. The more 
fixed position of the mass, the recognition of resonance over 
the tumor, and, particularly, the ability to demonstrate, through 
rectal palpation, the presence of the rectum in front of the tumor 
will assist in the diagnosis. 

Other Abnormal Collections and Growths. — The uterus can 
present morbid collections, such as physometra, hydrometra, 
and hematometra. Physometra is a collection of gases within 
the uterus, the product of decomposition, and is a rare con- 
dition. Hydrometra, a collection of watery fluid within the 
uterus, mostly occurs in women of advanced years, and is caused 
by retention of the secretions after obliteration of the canal. 
Hematometra is a collection of blood in the uterus, — as the 
retention of the menstrual discharges from occlusion of the 
cervix or vagina, — and it mostly occurs near puberty. In- 
spection and bimanual palpation are sufficient to disclose the 
cause. The situation of renal and hepatic cysts is sufficient 
to release them from the suspicion of an ovarian origin. 

Third, the relation of the tumor to the surrounding parts, the 
character of the pedicle, and the presence of adhesions: 

Adhesions. — The mobility of the tumor is dependent upon 
the length of the pedicle and upon the absence of adhesions. 
A tumor which can be pushed up without much dragging upon 
the uterus, displaced from side to side, and the abdominal 
walls recognized as sliding over it, is reasonably free from ad- 
hesions, and has a long pedicle. A tumor which is situated 
upon one side of the pelvis, and pushes the uterus to the op- 
posite side, and which is quite immovable, or drags upon the 
uterus as it is moved, is, without doubt, an intraligamentary 
cyst. Rapid enlargement, tenderness of the abdomen, and 
a sensation of crepitus as the abdominal wall is being moved 
over the tumor indicate recent and extensive adhesions, the 
result of peritonitis. Limited adhesions with omentum, in- 
testines, and abdominal wall can not be excluded. In very 
large cysts it is frequently difficult to diagnose the presence 
of adhesions. Information can often be secured by observing 
the respirations. In deep inspiration we can feel and see the 
upper pole of the tumor pushed down, unless it is fixed. The 
ability to drag the uterus down will assure its freedom. If 
the fundus uteri remains high when the bladder is empty, it is 
adherent. The history is valuable, as adhesions occur in torsion 
of the pedicle, in inflammatory changes, and from traumatism. 



OVARIAN TUMORS. 835 

Torsion of the pedicle is recognized by the complication 
of an ovarian tumor with sudden and severe peritoneal symp- 
toms. These are severe pain in the belly, meteorism, vomiting, 
elevated temperature, rapid growth of the tumor, and tenseness 
of its surface, which indicate that the torsion has been followed 
by intracystic hemorrhage or increased exudation. 

When the patient is seen long after the torsion, the tumor 
is ever3rwhere adherent, and the patient may show distinct 
evidences of marasmus. Sudden collapse, followed by symp- 
toms of internal hemorrhage and by peritoneal irritation, in- 
dicate the occurrence of an internal hemorrhage. In the acute 
stages of torsion it is often difficult to arrive at a differential 
diagnosis from rupture of an ovarian cyst, peritonitis, perfora- 
tion of the stomach or intestine, renal or gall-stone colic, ileus, 
and rupture of an ectopic gestation. An attentive considera- 
tion of the history and progress of the disorder will lead to a 
direct conclusion. Inflammation of a tumor is determined by 
the accompanying symptoms. The tumor is very sensitive, 
and presents a spontaneously localized, sometimes radiating 
pain. The tumor may suddenly enlarge, or the suppuration 
may lead to the formation of gas and the development of a 
tympanitic resonance. Perforation of a suppurative tumor 
into the bladder or intestine is recognized by tenesmus and 
irritation of the bladder or by diarrhea and intestinal colic. 
Perforation is certain if portions of the tumor or its contents 
are found in the discharges. Rupture of a cyst is determined 
by the associated phenomena. Sudden oppression, suffocation, 
nausea, sometimes vomiting, diarrhea, acceleration of the 
pulse, and moderate elevation of temperature indicate the 
entrance of fluid into the peritoneal cavity. This is rendered 
more probable by strong diuresis and a perceptible decrease 
in the size of the tumor, with the presence of free fluid in the 
peritoneal cavity. The distinct tumor limits are not found, 
and there is no alteration of resonance with change of position. 

Fourth, the variety of the ovarian tumor. The glandular 
proliferating cyst is the most frequent form and attains the 
largest size. These tumors are mostly multilocular, and con- 
sequently present a less marked wave of fluctuation upon pal- 
pation. Fluctuation is an indication of the cystic character 
of the tumor, and is very distinct in the unilocular and large- 
chambered varieties. Instead of fluctuation we often find 
a kind of elasticity, which can be produced by edematous solid 
growths, and in large cysts the contents of which are made 
up of colloid or very thick, viscid material. In some cysts, 
instead of fluctuation, only a kind of vibration is determined. 
In fluctuating or tough elastic tumors AA^hich are nodular we 



836 GYNECOLOGY. 

will probably find a cystadenoma. A large fluctuating tumor 
is not necessarily a unilocular cyst, because it may contain 
within it numerous small cysts. 

Generally, a small cyst which presents no symptoms is 
not a cystadenoma, but may be a dermoid, a parovarian, or, 
more probable than either, a simple retention cyst of the ovary 
or a simple serous cyst. Dermoid tumors are recognized by 
their irregular consistency — in some places soft, in others hard. 
A doughy feel has been ascribed to them, but this is rare, as 
the fatty material at the body-temperature is fluid, and it 
is only in the presence of a large amount of hair that the doughy 
sensation can be elicited. The determination that the tumor 
had been in existence for ten or more years would justify the 
suspicion of a probable dermoid. Olshausen says that parovarian 
growths are mostly determined by their moderate size, slow 
growth, thin and relaxed walls, the translucent fluid contents, 
and the very distinct fluctuation. Parovarian tumors, as a 
rule, are spheric, though from their relaxed condition they 
may assume other forms, especially when pressed into the pelvis. 
Large cysts are generally multilocular. The presence of double 
intraligamentary growths, as well as of ascites with small tumor 
formation, is a presumption, but not a positive indication, of 
papillary growths, as the conjunction of symptoms is found 
in all tumors. Superficial papillomata feel firm, nodular, and 
are often diffusely extended in the pelvis. In a rapidly develop- 
ing ascites, in which renal, cardiac, and hepatic causes can be 
excluded, the presence of bilateral resistance in the pelvis should 
awaken a suspicion of ruptured papillary ovarian cyst. A 
pronounced solid consistency of the growth is common to ovarian 
fibromata, sarcomata, endotheliomata, carcinomata, and terato- 
mata. 

It should not be forgotten that cystic conditions can com- 
plicate in all these tumor formations. As a rule, ascites is 
present, and this, by increasing the difficulty of palpation, 
renders the diagnosis more uncertain. The fibromata and 
the fibrosarcomata are less nodular, of quite firm consistence, 
and are more frequently situated upon one side. Sarcomata 
and endotheliomata are generally softer. The solid carcino- 
mata are mostly bilateral, quite nodular, and offer a sensation 
of toughness. There are no positive indications that a tumor 
is benign or malignant, as a cystadenoma may contain masses 
of cancer material. Ascites is generally regarded as an in- 
dication of malignancy, but it occurs in pseudomucin cysts, 
papillary growths, and with the fibromata. Hard consistency 
and an irregular surface are also reasons for suspicion, but are 
not positive -indications. Early adhesion of the vault of the 



OVARIAN TUMORS. 837 

tumor, which prevents the vaginal wall from being moved 
over it, is an indication of malignancy, when abscess forma- 
tion can be excluded. 

The age of the patient is of little significance, as the age 
of puberty is inclined to the formation of cancer, and all varie- 
ties of ovarian tumor can occur at any period of life. Proper 
metastases, as distinguished from peritoneal implantation, are 
of significance, but it is not always easy to demonstrate these 
metastases, as they do not always cause symptoms, or are not 
perceptible because of the abundant ascites. In other cases 
metastases will have been discovered in the vagina, the para- 
metrium, and the rectal and peripheral lymph-glands before 
operation, fixing the diagnosis of malignancy without question. 
Pronounced cachexia and marasmus may be produced by certain 
complications, such as rupture, torsion, and infiammation; 
also in tumors of enormous size. Rapid growth, especially 
in children, speaks for malignancy. Olshausen directs attention 
to the premature edema of a leg as a symptom of cancer. 

640. Exploratory Puncture. — In obscure and complicated 
cases it was formerly the rule before resort to operation to 
draw oft' a portion of the cyst-contents for chemic and micro- 
scopic examination. The fluid may have such pronounced 
physical properties as to reveal the true character of the growth. 
The thick colloid material from proliferating cysts can be mis- 
taken for nothing else. If the fluid is serous, the possibilities 
of origin are numerous. It may have been furnished by a 
parovarian cyst, a serous ovarian tumor, a cystadenoma, ascites, 
hydronephrosis, and echinococcus sacs. In uncomplicated cases 
the fluid may possess such chemic properties as will aid in the 
differentiation, but frequently these properties are lost through 
complications, such as serous transudation and an admixture 
of blood. The fluid from a proliferating cyst is thick and colloid, 
with a specific gravity of from 1015 to 1030, and contains par- 
albumin and cylindric cells. In the papillary cysts there is 
an absence of paralbumin, while white blood-corpuscles are 
revealed by the microscope. The fluid from the Graafian 
follicles does not differ from that of the parovarian cysts. As- 
citic fluid is thin and of a light yellow or greenish color, from 
which albumin is coagulated upon boiling, but no cylindric 
epithelium is found, and the specific gravity is from 1008 to 
1015. In the cystic fibroma the fluid is of a lemon-yellow 
color, has a specific gravity of 1020, coagulates rapidly without 
heat, and contains no cylindric epithelium. The fluid from 
echinococcus cysts presents booklets, has a specific gravity 
of from 1008 to loio, and does not contain albumin. In 
hydronephrosis the fluid is thin, with a specific gravity of from 



838 GYNECOLOGY. 

1005 to 1018 ; its color varies, and it contains urea, leucin, tyrosin, 
and kreatinin. Puncture of a cyst is always attended with 
danger, and when performed in doubtful cases, for diagnostic 
purposes only, — as in the echinococcus cysts, renal tumors, 
abscesses, and dermoids, ^ — is attended with the most serious 
consequences: the intestines and bladder have frequently been 
punctured; fluid may escape into the peritoneal cavity and 
cause peritonitis; or air may enter the sac and result in in- 
flammation and suppuration; a large vessel in the sac-wall 
has been injured, and a severe and dangerous hemorrhage 
has resulted. Neither chemic nor microscopic examination 
of the cyst-contents affords positive information, and the in- 
ferences thus secured do not compensate for the increased 
danger the patient undergoes. 

641. Exploratory Incision. — In cases in which we find it 
impossible to arrive at a positive diagnosis, as in tubercular 
peritonitis, in malignant disease of the ovary, tube, or omen- 
tum, or in papillary cysts, a button-hole incision, sufficiently 
large to permit the introduction of the finger, will be a far safer 
procedure than puncture, and will afford an opportunity to 
determine the condition by touch, and will permit subsequent 
drainage. It should be done under all antiseptic precautions, 
and every preparation should be made to complete the opera- 
tion if the conditions will permit. While this procedure is 
unattended with great danger, its indiscriminate practice is un- 
justifiable. It should not be utilized to secure information that 
may as well be secured by the bimanual examination. When 
the latter procedure has demonstrated an inoperable malig- 
nant condition, for instance, the incision should not be made 
merely for confirmation of the decision. 

642. Treatment. — -That an ovarian cyst is not amenable 
to medicinal treatment is evident when we consider that the 
fluid is contained within a shut sac, which has its own secreting 
surface. The administration of remedies, and the application 
of counterirritants with a view to increase secretion and elim- 
ination, must be without avail. Electrolysis has had its 
advocates, but when we consider the character of these growths, 
and the danger from infection many of them must present, the 
folly of such treatment is evident. Surgical treatment should 
consist in extirpation. Puncture is but a palliative procedure 
at best, for the removal of the fluid is quickly followed by its 
re-formation, and it requires more and more frequent with- 
drawal, which proves a severe drain, through the great loss 
of albumin. As has been stated, it is associated with danger 
from the puncture of a large vessel in the tumor wall, and the 
consequent hemorrhage; from the possibility of infection by 



OVARIAN TUMORS. 839 

escape of the contents of a papillary cyst, or the rupture of 
so thin-walled a cyst and the escape of its contents into and 
over the peritoneal cavity; and, lastly, from septic infection. 
Puncture may be resorted to as a temporary measure in a tumor 
complicating pregnancy, when the cyst is so situated as to 
form an obstruction to labor, and then should be performed 
through the vagina, after the most thorough cleansing of that 
canal. Puncture of a cyst through the rectum, under any 
circumstances, is an unjustifiable procedure. 

643. Ovariotomy. — Extirpation of the tumor, or, as the 
operation is known, ovariotomy, is the only operation worthy 
of consideration as applicable to all- cases. Success in its per- 
formance Avill depend very much upon the care with which 
the diagnosis has been made, the knowledge of the operator 
as to the condition of the patient, the dexterity with which 
the operation is performed or the readiness in meeting complica- 
tions, and the judicious treatment of the patient subsequent 
to its performance. 

644. Indications. — The recognition of the danger of every 
operation upon the peritoneum led the early operators to post- 
pone interference until the patient had begun to experience 
marked discomfort and was suffering in general health from 
the pressure of the growth. The introduction of the principles 
of antisepsis and asepsis have rendered postponement unneces- 
sary. A more careful study of the progress of the growths 
has demonstrated that it is unwise to postpone operation after 
a tumor has attained a growth sufficient to permit of diag- 
nosis, because of the various complications which can develop. 
A large proportion of ovarian tumors are of a malignant char- 
acter. Schultze places the proportion of malignancy at 27 
per cent, of all ovarian tumors; Ruge, at 15 per cent. These 
variations are dependent upon their appreciation of the re- 
lation of papillary formations to malignancy. Pfannenstiel 
found among 400 cases in which were included parovarian 
tumors that 19 per cent, were malignant. Reckoning the 
papillary adenomata, the number equaled 26.15 P^^ cent. — 
a proportion that agrees with the estimates of Schultze and 
Leopold. It will be seen from these statements that about 
every fourth or fifth ovarian tumor can be considered malig- 
nant. The diagnosis of malignancy can not be made with 
certainty. If it is recognized that safety in these cases lies 
in the earliest possible extirpation, it will be evident that in 
one-half of all the cases the early extirpation of the tumor 
will be indicated. Absolutely benign growths of the ovary 
are unlimited in their size, and thus cause symptoms which 
imperil the life of the patient and lengthen the time required 



840 GYNECOLOGY. 

for recovery. Delay favors the development of complications 
which, if they do not threaten life, create conditions that render 
the later operation more difficult and the prognosis less certain. 
These circumstances, with the present favorable prognosis 
of ovariotomy, render it desirable that every ovarian tumor 
should be subjected to operation as soon as it attains a size 
sufficient to permit of its diagnosis. It was formerly advised 
to wait until the tumor had reached a size that would permit 
it to rest upon the pelvis, but no limit is now known, and the 
operator prefers to remove the tumor as soon as the patient's 
permission can be secured. The inability to determine the 
exact character of the growth, and the possibility of very small 
papillary tumors infecting the entire abdominal cavity, make 
early operation advisable. 

The severity of the symptoms only come into considera- 
tion as they assist the patient in arriving at a favorable de- 
cision. The difficulties of the operation should not be a cause 
for delay, as they will not become less by waiting. The stage 
of life plays no role in the decision unless the growth is com- 
plicated by acute tubal disease, which may render temporary 
delay desirable. 

The indication for operation should be considered as urgent 
when the tumor begins to grow rapidly or when symptoms 
of threatening complications appear. Compression of the 
lungs, symptoms of uremia, of ileus, of intraperitoneal or intra- 
cystic hemorrhage, or rupture of the cyst must be considered 
as urgent and vital indications. More frequent complications 
are torsion of the pedicle and inflammation and suppuration 
of the cyst. The existence of peritoneal irritation has been 
considered as a reason for delay in operating, but now we realize 
that the patient has a much better prognosis through early 
operation than when it is delayed. 

645. Contraindications. — The reasons for withholding opera- 
tion may be transitory or permanent; the former, in severe 
complicating diseases, as intercurrent fevers, bronchial catarrh, 
especially in the aged, progressive weakness from loss of blood, 
or obstinate gastro-intestinal catarrh. The menstrual period 
is sometimes regarded as such a cause, but as it does not in- 
crease the danger of infection, it is no bar. The permanent 
contraindications are: irrecoverable disease of the heart, lungs, 
kidneys, or liver, marasmus, especially senile, and such dis- 
eases as will in a short time certainly lead to death. While 
pulmonary tuberculosis, valvular disease of the heart, and 
nephritis are contraindications, ovariotomy occasionally de- 
creases the danger from the lesion. 

Age is no contraindication, as a number of successful opera- 



OVARIAN TUMORS. 841 

tions after the age of eighty are reported. The mortality of 
loo cases operated upon after the age of seventy was 12 per 
cent. (Kelly). Ovariotomy is not contraindicated by age 
unless the tumor is associated with some disease which will 
render death certain in a short time. 

A number of anatomic contraindications were formerly 
recognized, among which were adhesions, intraligamentary 
growths, and the existence of malignity. Adhesions are no 
longer considered a reason for delay, and frequently the re- 
lation of the tumor to the broad ligament is discovered only 
during the operation. In the majority of cases the attempt 
at the operation only terminates with its completion. While 
the most trifling hope of recovery exists, and no traces of cachexia 
and metastasis formation are present, the operation should 
not be considered as contraindicated. 

646. General Considerations. — Unless immediate operation 
is indicated by torsion of the pedicle, rupture of the cyst, or 
indications of cystic hemorrhage, two days should be occupied 
in the preparation of the patient, during which the pulse, tem- 
perature, condition of the respiratory organs, and urine can 
be studied. In complicated cases the procedure may be longer 
delayed, until the condition of the patient can be corrected. 
In very large cysts, with marked edema and dyspnea, many 
authors advocate a preliminary puncture, in order that the 
lungs and kidneys may have a iew days to recover their 
functions before the major operation is performed. Because 
of its many disadvantages, puncture should be done A'ery 
infrequently. For the performance of ovariotomy the follow- 
ing assistants are desirable: First, a principal assistant, who 
stands opposite the operator; second, the anesthetist; third, 
a nurse or a physician to arrange and serve the ligatures and 
sutures; fourth, a second nurse, to care for the sponges; and, 
fifth, a nurse to serve in changing the water for the sponges 
and for the hands of the operator and his assistant. All these 
persons should be trained to know and to do their duty. Direc- 
tions for their preparation are given. (Section 115.) 

Instruments. — A knife, two pairs of scissors, two long dis- 
secting forceps, twelve small and six large clamp forceps, two 
ligature carriers, a needle -holder, an angiotribe, a trocar, a 
tube, two pairs of cyst forceps, and two short and four long 
curved needles, each threaded with a double silk loop for carriers, 
should be provided. The instruments should be carefully 
sterilized and placed in sterile trays. The patient should be 
placed upon a suitable table, with her feet toward a good light. 
An ordinary kitchen table will serve well. The operator stands 
to the patient's left and his assistant opposite. To the right 



842 GYNECOLOGY. 

of the operator is a table, upon which are placed the tray con- 
taining the instruments; a smaller one, for the needles and 
ligatures; and a basin with sterile water, for the hands of the 
operator, which should be changed as often as it becomes soiled. 
Behind the principal assistant stands another table, on which 
are two basins for the sponges or pads, and a third for the as- 
sistants' hands. The soiled sponges are washed out in one of 
these basins and placed in the other, from which they are squeezed 
out and handed to the assistant for the operation. These 
sponges should be accurately counted before the operation 
is begun, and all should be accounted for before the wound is 
closed. Want of care may result in the retention of a sponge, 
a pad, or even an instrument within the abdominal cavity, 
to the great disadvantage of the patient and to the discredit 
of the surgeon. A third table should hold the dressings, ready 
for application. There should be on hand in the room hot 
and cold sterilized water, at least five gallons of each, slop buckets, 
a normal salt solution for irrigation of the abdominal cavity, 



Fig. 532. — Cyst Forceps. 

and a suitable apparatus for hypodermocleisis or transfusion, 
if the condition of the patient should demand it. In addition, 
there should be within the reach of the anesthetizer a hypoder- 
mic syringe and solutions of strychnin and atropin. 

647. Operation. — The description of the operation we prefer 
to divide into steps or stages, and to describe the method of 
procedure in each. We can thus afford the operator a graphic 
outline of the various accidents which can occur, and the methods 
to which he may be compelled to resort as he proceeds. He 
will be unlikely to mistake his course on the journey if an ac- 
curate chart of each portion is furnished him. 

The different stages are: 

1. The incision of the abdominal wall in the median line 
or through one rectus muscle, securing all bleeding vessels with 
hemostatic forceps before the peritoneum is opened. (See Sec- 
tion 133.) 

2. The puncture and evacuation of the cyst. 



OVARIAN TUMORS. 



843 



3. The removal of the cyst and management of the adhesions. 
(See Section 134.) 

4. The method of controlhng the circulation through the 
pedicle. 

5. The examination of the other ovary and of the general 
peritoneal cavity for bleeding vessels; the removal of all gauze 
pads. (See Section 135.) 

6. Drainage. (Sections 136, 137, 138, 139, 140.) 

7. Closure of the wound. (Section 141.) 

8. Dressing. (Section 142.) 




Fig- 533- — Wall Incised; Cyst Exposed. 



I. The Incision of the Abdominal Wall. — It was formerly 
preferred to open the abdominal wall in the median line, cutting 
through, if possible, the linea alba. It is, however, better 
to f cut through one or the other rectus muscle, as the subse- 
quent apposition of the various surfaces secures a stronger 
ventrum. The linea alba is the weakest part of the abdominal 
wall, hence it seems unwise to increase its weakness by making 
a wound through it when the incision to one or the other side 
when properly united will be as strong aj before it was made. 
There is a little more tendency to bleeding when the incision 
is made through the rectus muscle; but it is easily controlled 
by hemostatic forceps, and if it continues to bleed after their 



844 



GYNECOLOGY. 



removal, the ligation of the bleeding vessels can be easily ac- 
complished. The peritoneum is picked up, pulled away with 
two pairs of forceps from the tumor wall and an incision is made 
through it. This avoids injury to the tumor wall or to a knuckle 
of intestine which might be situated over it. The peritoneum 
is incised the length of the wound so that it will not be likely 
to be pushed off during the subsequent manipulation. 

2, Puncture and Evacuation of the Cyst. — A number of more 
or less ingenious trocars have been devised for evacuating the 
contents of the cyst. What is required is a cannula with a 
tube attached, through which the fluid can be carried to a re- 




Fig. 534. — Cyst Punctured and Being Withdrawn. 



ceptacle beneath the table. The simpler and more readily 
cleansed this apparatus, the better. A glass nozle for a fountain 
syringe, together with three feet of rubber tubing, will serve 
very well. A glass tube of larger caliber will prove more effec- 
tive when there is a large quantity of fluid to be evacuated, or 
where the fluid is very viscid. A cannula, however, is not a 
necessary part of one's equipment, for the cyst contents can be 
readily evacuated through a knife thrust, but at the expense 
of greater soiling of the room and clothing. 

The point chosen for puncture should be situated toward 
the upper portion of the wound, so that the contraction of 



OVARIAN TUMORS. 845 

the emptying cyst will not draw the opening within the ab- 
domen. As the cyst contracts, its opening can be drawn through 
the wound to serve as a funnel to carry away the fluid. When 
the cyst is a large one, I would advise that the patient be turned 
upon her side, the assistant making firm pressure to keep the 
cyst pressed into the wound as it empties. This position favors 
the rapid evacuation of the cyst contents, with the least danger 
of the entrance of the fluid into the peritoneal cavity. When 
the operator has provided himself with sterile basins he can 
collect the fluid and obviate soiling of the body of the patient, 
her sterile environment, and the room with its contents. The 
lateral position also is favorable in necrotic cysts, as it permits 




Fig. 535. — Withdrawal of Sac, Showing Adhesions. 

their removal with less soiling of the general peritoneal cavity. 
The precaution to obviate soiling the peritoneal cavity is es- 
pecially important when the cyst contents are purulent. The 
careful observations of Watkins have demonstrated that the 
contents of these cysts are often especially virulent, producing 
fatal peritonitis or other form of sepsis whenever the infection 
has found lodgment within the abdomen. Large vessels in 
the cyst -wall should be avoided in making the puncture. Gauze 
pads should be held about the margins of the wound while 
an assistant with both hands upon the abdomen keeps the 
cyst- wall pressed against the abdominal wound. When a 
cannula is not employed, the operator should seize the edges 



846 GYNECOLOGY. 

of the cyst wound and forcibly draw them out. This protects 
the peritoneal cavity from any soiling, especially when the 
patient occupies the lateral position. When a cannula is used, 
the relaxed cyst upon either side of the cannula is caught with 
suitable forceps and drawn out. In nonadherent cysts this 
procedure will permit the removal of the sac, when empty, 
without any soiling of the abdominal cavity. In multilocular 
cysts the largest cyst exposed is first evacuated, through which 
succeeding cysts may be evacuated, drawing the first out to 
serve as a funnel. Areolar and dermoid cysts are best removed 
without effort at their reduction, because the contents, es- 
pecially of the latter, are irritating to the peritoneal cavity 
and difficult to remove from it. Occasionally, the cyst -con- 
tents are so viscid that they refuse to run through the cannula. 
The edges of the puncture are seized and the sac is drawn forcibly 




Fig. 536. — Ligatures Introduced Fig. 537.— Interlacing of Sutures to 

through Broad Pedicle. Prevent Splitting of Pedicle. 

against the wound, while the opening is enlarged and the jelly- 
like contents are scraped away. 

4. Management of the Pedicle. — When the tumor is large 
and heavy, the pedicle may be seized with clamp forceps and 
the cyst cut away, after which the stump should be crushed 
with the angiotribe, and ligated in sections, or ligatures applied 
only to the larger vessels. When the pedicle is long and thin, 
a ligature may be thrown around it and tied in the groove made 
by the angiotribe. In a short, broad pedicle this is not feasible, 
but the section method, illustrated upon these pages, serves 
an excellent purpose. 

When tied in several sections, the ligatures should inter- 
lace, in order to prevent the pedicle from splitting. The Downes 
electric angiotribe affords an excellent method of securing 
against hemorrhage, and leaves the wound without the irritation 
of a foreign body. In a cyst without a pedicle the sac should 
be enucleated and the vessels secured as the operation pro- 



OVARIAN TUMORS. 847 

ceeds. These cases present some of the most trying problems 
within the realm of abdominal surgery. In cutting away the 
tumor the precaution must be exercised to retain a sufficient 
button to prevent the ligature from slipping. If a ligature 
slips on a short, broad pedicle, the parts spread out, the vessels 
retract, and serious hemorrhage occurs, which ma}^ be difficult 
to control. Sometimes the ovarian or uterine artery slips back 
and forms a hematoma in the stump, which so fills up the tissues 
as to make sufficient traction upon the ligature to withdraw 
the tissue, from which a fatal hemorrhage follows. The tendency 
of the tissue external to the ligature to shrink after the removal 
of the tumor should not be forgotten, and when the traction 
is severe, a second ligature may be judiciously placed behind 
it to inclose the ovarian artery. Silk, wire, and animal ligature 
have been employed for securing the pedicle. Silk, from its 
strength, ease of preparation, and small amount of material 
required, is most frequently employed. I prefer the chromic 
catgut, but the precaution must be exercised to tie it tight 
and to leave a secure 
button, because of its 
greater propensity to 
slip Other methods of 
securing hemostasis have 
been employed : the ves- 
sels have been twisted; 

for many years the pedi- Fig. 538. — Sutures Interlaced and Tied. 

cle was brought out of 

the wound and clamped ; Keith applied a temporary clamp and 
charred the tissues with the hot iron ; Skene improvised a set of 
electrocautery clamps, by which the tissues are slowly burned 
through and the application of the ligature is avoided. This 
apparatus has been greatly improved and made practicable 
through the ingenuity of Dr. A. J. Downes, of this city. 

General Considerations. — The study of the differential diag- 
nosis of ovarian tumors should have prepared the operator 
to appreciate the fact that, after the m^ost careful investigation 
of his cases, he must not infrequently expect to meet with con- 
ditions entirely different from those which the physical signs 
have indicated. Not infrequently what appears a simple ovarian 
cyst will present complications that it will test the ingenuity 
of the most experienced operator to overcome. The inex- 
perienced operator should prepare himself for every emergency, 
and should have previously planned for them, as the prudent 
general plans for the coming battle. The more carefully the 
case has been studied, the patient prepared, and the emergencies 
anticipated, the more certain will be the success. It is far 




848 



GYNECOLOGY. 



better to go to unnecessary preparation many times than to 
be unprepared once. Patients with large ovarian cysts fre- 
quently suffer from pressure symptoms, and are greatly benefited 
by previous purgation, stimulation of the secretion of the kid- 
neys and skin, and the administration of strychnin and atropin 
to strengthen the action of the heart and vessels. In the in- 
cision care is exercised to avoid pushing off the peritoneum 
and to escape injuring the bladder, a loop of intestine, or the 
cyst. The bladder may be drawn up to a higher level by ad- 
hesions to the cyst. It is recognized by the arrangement of the 
muscle-fibers in its wall. The parietal peritoneum is occasion- 
ally inseparable from the surface of the tumor along the line 



,4-' 



LIGATURE 
ONO/AR!AN. 



ARTER 



/^^v 



'■■•"* /m jm 




r 



Fig. 539. — Splitting of Pedicle when Sutures are Tied without Interlacing. 



of incision, when the cyst may be opened and emptied before 
proceeding to the separation of the adhesions. 

The intestine is rarely in danger of injury during this stage 
of the procedure, but occasionally a loop may be situated in 
front of the cyst. 

The removal of a cyst should be followed by the examina- 
tion of the remaining ovary. Frequently it will be found to 
be the site of a cyst which would otherwise be overlooked. 

The toilet of the peritoneum should not be understood 
to mean thorough drying of the cavity; indeed, much spong- 
ing and manipulation of the peritoneum are injurious, and favor 



OVARIAN TUMORS. 849 

the formation of adhesions. The cavity is most readily cleansed, 
and with the least injury, by irrigation with normal salt solu- 
tion. The retention of a considerable quantity of the fluid 
is beneficial, in that it favors peristalsis, and by its absorption 
replenishes the liquid waste. Ragged omentum and shreds 
or bands of adhesions should be removed. When the irrigating 
fluid continues to come away bloody, careful examination 
should be instituted to ascertain the source of the bleeding. 
The abdomen must not be closed while a considerable quantity 
of blood is being lost. Unless the abdomen has been soiled 
with infective cyst contents it is better not to irrigate. If 
the precaution has been exercised to protect the cavity by 
gauze packing, irrigation will be very infrequently required. 
A saline solution is probably the least irritating of anything 
that can be introduced into the peritoneal cavity, but even it 
handicaps to some degree the functions of this extensive ab- 
sorbing surface. 

Post-operative Treatment. (Section 143.) 

648. Incomplete Operation. — The conditions in which the 
operation has not been completed are most frequently those 
of intraligamentary parovarian cysts, and particularly papil- 
lary cysts. The structure of the broad ligament is more or 
less involved, and not infrequently adhesions affect a large 
portion of the intestine. The more experienced the operator, 
the less frequently will the incomplete operation be performed. 
With judicious measures, cases in which the operation can 
not be completed are exceedingly rare. In the intraligamentary 
variety an incision of the peritoneum, where it is situated about 
the base of the tumor, is made, the tumor is drawn up, form- 
ing a pedicle, and the tissue is pushed off by blunt dissection. 
Sometimes the tumor may be opened and an incision made at 
its base, by which the sac is then dissected out. Frequently 
it is advisable to precede the operation by ligation of the larger 
vessels, particularly the ovarian arteries, after which the dis- 
section can be accomplished with less hemorrhage. Adhesions, 
when in the cords and bands, can be cut with the Paquelin 
cautery. In the papillary variety it is very important that the 
mass should be removed, even if it is necessary to extirpate 
the uterus to accomplish it. Frequently what seem desperate 
cases recover when the original source of the disease is removed, 
even though extensive infection of the peritoneal cavity has 
occurred. When adhesions are very extensive and the con- 
dition of the patient such as to preclude the possibility of com- 
plete removal of the sac, its cavity should be emptied, cleansed, 
and sutured to the parietal peritoneum of the abdominal wall, 
while the remaining portion of the wound is closed. The sac 
54 



850 GYNECOLOGY. 

cavity is packed with iodoform gauze. Thus it may be kept 
open, irrigated from time to time with disinfectant solutions, 
and the packing renewed until the cavity fills by granulation. 
This procedure is necessarily attended with increased danger 
to the patient, as it is impossible to keep such a wound com- 
pletely aseptic. 

When a tumor is deeply situated in the pelvis, the abdominal 
opening may be closed after an incision has been made through 
the base of the tumor into the vagina, through which the end 
of the gauze packed into the cyst may be carried. Over this 
gauze the cyst- wall is closed, and covered, when possible, with 
peritoneal flaps. Intraligamentary tumors are sometimes pushed 
up into the mesentery, and the removal of the mass necessitates 
the ligation of important branches of the mesenteric artery. 
When a large portion of mesentery is thus ligated, the vitality 
of the portion of intestine supplied by it is endangered and 
gangrene of the gut may result. Such cases may demand 
the excision of the affected portion of the intestine and an end- 
to-end anastomosis. In metastasis of the papillary variety 
into the omentum, forming, as it frequently does, good-sized 
masses involving the entire omentum, the latter should be 
removed after ligation of its base with a number of catgut liga- 
tures. It was my privilege, in a patient who had double-sided 
papillary ovarian cysts, with extensive ascites from the infected 
peritoneum, and who had been subjected three times to ab- 
dominal section for the evacuation of this fluid, to remove 
both ovaries and the greater part of the uterus after an exten- 
sive dissection. The entire omentum was also removed. This 
patient, in whom the dropsical effusion had previously collected 
so rapidly that they were unable to get her out of bed after 
operation before the fluid had reaccumulated, had no recur- 
rence of effusion subsequent to the complete operation, and 
two years later was in good health. 

649. Rupture of the Cyst. — In cysts of the glandular variety 
which have been greatly distended, or when the pedicle is partly 
twisted, the cyst- wall becomes fragile and is easily torn, per- 
mitting its contents to escape into the abdominal cavity. This 
accident is not a serious one unless the cyst contents have 
undergone degeneration, as in suppurating cysts, or are irritat- 
ing in character, as in the dermoid varieties. Tearing the cyst- 
wall will necessitate a thorough irrigation of the abdominal 
cavity to neutralize or to remove the contents. 

650. Hemorrhage. — The site of the hemorrhage will greatly 
influence its character. In large cysts with extensive adhesions 
hemorrhage may take place from the cyst-wall or from vessels 
that have been torn within its walls and threaten a fatal re- 
sult. The adhesions should be separated rapidly, the cyst 



OVARIAN TUMORS. 851 

raised, and its pedicle secured to cut off the blood supply. The 
larger and more vascular adhesions should be separated between 
ligatures or clamp forceps. If the hemorrhage threatens life, 
the assistant may place his hand within the abdomen, com- 
press the abdominal aorta, and maintain the pressure until 
the operation is completed. Such a procedure prevents the 
further supply of blood, and so arrests the bleeding. Hemor- 
rhage may occur from a very extensive surface, particularly 
when malignant disease has been the subject of removal, or 
extensive papillary growths which are intraligamentary or be- 
hind the uterus. Fatal syncope and death may follow the 
removal of very large tumors as a result of decreased ab- 
dominal pressure. The vessels relieved from pressure become 
distended by the blood, and form extensive reservoirs, by which 
so much of the blood is withdraw^n from the circulation as to 
cause cerebral anemia and the death of the patient. Such 
a patient can be said to have bled into her own vessels. Such 
an occurrence is likely to take place only in very large tumors, 
and may partly be obviated by emptying the cyst slowly. When 
syncope occurs, the head should be lowered, and an assistant 
may compress the abdominal aorta with the hand in the ab- 
domen, while the treatment of the pedicle and the toilet of 
the abdomen proceed. Occasionally, it may be necessary to 
remove the uterus on account of the free bleeding from its 
torn and denuded surfaces. The vitality of the patient may 
be maintained by hypodermic injections of strychnin, gr. -gV-rV 
hourly or every two hours, a i : looo solution of adrenalin chlorid. 
gtt. x-xv every hour, atropin, gr. y-^-jj, to contract the blood- 
vessels, or a hypodermocleisis of normal salt solution. The 
salt solution can be poured directly into the abdominal cavitv 
while the patient is in the Trendelenburg posture, or transfused 
directly into a vein. The latter measure affords an increased 
quantity of fluid by which the vessels can be filled and the heart 
have something upon which to contract. 

651. Visceral Injuries. — Injuries to the intestine are possible 
during complicated operations. In making the abdominal 
incision it is important that the peritoneum should be raised 
with forceps, and a small opening made, to prevent not only 
injury of the cyst- wall, but of a possible loop of intestine which 
may be adherent over it. With the opening, the incision in 
the peritoneum can be extended the full length of the external 
wound by holding it up and incising it under the eye. In very 
dense adhesions the intestines may be torn into, or even across, 
during the progress of the operation. When such a lesion 
occurs, the parts should be carefully repaired at once, and 
measures should be taken to prevent soiling the peritoneal 
cavity with the bowel-contents. The intestine should be care- 



852 GYNECOLOGY. 

fully sutured, and when torn through to such a degree as to 
render its vitality uncertain, resection should be done and an 
end-to-end anastomosis made. This procedure is accomplished 
very quickly with the Murphy button or one of the mechanical 
devices for holding the ends of the divided gut, especially the 
O'Hara forceps. In the absence of these instruments, the 
anastomosis may be performed by first suturing the mesenteric 
surface of the bowel by a single suture, another just opposite 
to this, and then one on each side between the first two. This 
divides the bowel into four sections, each section of which can 
be rapidly closed by continuous suture. The needle is passed 
through the loop of these sutures at every other insertion, which 
prevents puckering and contraction of the lumen of the bowel. 
The first row of sutures should be covered by a second, and this 
also covers over the sutures we have employed to maintain 
the ends together. A still better procedure is to introduce 
an interlocking continuous suture from the mucous membrane 
side of the bowel, and superimpose this by a similar suture 
in the peritoneal covering. Such a closure is rapidly accom- 
plished and very effective. The closure can be made with 
fine silk or chromic catgut, or the internal may be made with 
the former and the external (or peritoneal) with the latter. 

The most difficult cases for suture are those in which the 
rectum has been torn low down in the pelvis. Portions of 
the bowel may be so devitalized that they will not subsequently 
hold, and a fecal fistula follows. In all cases in which the in- 
jury of the bowel has been extensive, and its condition endan- 
gered, the parts should be packed with iodoform gauze, which 
affords a vent in case union is not complete. Complete closure 
of the wound should be interdicted, because the patient would 
develop a dangerous peritonitis before the occurrence of rup- 
ture is recognized. The position and relation of the ureter 
should be kept in mind in tumors situated low in the pelvis, 
or in those which are developed in the broad ligament, and 
particularly in the papillary forms of ovarian growth, as the organ 
may be pulled up or torn off in the enucleation of such masses. 
When the tumor is so situated as to endanger the injury of the 
ureter, it is better to dissect out the latter to make sure that 
it is uninjured. AVhen it has been cut or torn, the preferable 
procedure is to establish an anastomosis between the divided 
ends. (Fig. 2 2 1.) If this is impracticable, then transplantation 
into the bladder should be performed. If the ureter is so short 
as to cause its vitality to be endangered by the necessary trac- 
tion, to reach the bladder the latter should be anchored to the 
side of the pelvis in a position most favorable to relieve the 
tension. The ureter may be introduced into the descending 



OVARIAN TUMORS. 853 

colon or an attempt may be made to introduce its end into 
the ureter of the opposite side; but one should hesitate in at- 
tempting the latter, as failure means the imperiling of the un- 
affected kidney and ureter. Its end may be brought out through 
the skin and a urinary fistula established, but this means an 
exceedingly uncomfortable condition for the patient. One 
alternative is to ligate the ureter, which should be done with 
double ligature, as a single ligature is likely under the process 
of absorption to become loose and permit a subsequent leakage 
of urine. The urine is secreted until the pressure from the 
distended pelvis is equal to that of the blood pressure, when 
secretion no longer occurs. The organ unused becomes atrophied. 
Another alternative is the extirpation of the kidney, and, be- 
fore attempting this, the operator should be well satisfied that 
the kidney on the opposite side is capable of doing the Avork. 

The bladder may be injured during an operation. It may 
be drawn up over the anterior surface of the tumor and be 
incised, or its fundus may be removed before its true character 
is suspected. The peculiar interlaced muscular structure of 
the bladder-wall should permit its recognition. AVhen it is 
opened or injured, it should be sutured. In a case of fibroid 
tumor in which it was my misfortune to cut away the entire 
summit of the bladder the walls were sutured, and the patient 
recovered. In such cases it is important that the bladder 
should be watched to prevent it becoming unduly distended 
during the convalescence. It should be frequently evacuated 
in order to avoid separation of weak union and leakage of urine. 

652. Prognosis. — The result of the operation of ovariotomy 
will depend greatly upon the manner in which it has been con- 
ducted. With the exercise of every precaution, there will 
frequently be cases of delayed convalescence, owing to latent 
or preexisting pathologic conditions; but the danger is greatly 
increased when the operation has been carelessly performed 
and its details imperfectly practised. The operator and his 
assistants should have been so well trained that no deviation 
from the proper course, even though slight, will be overlooked. 
What avails the most rigid cleanliness of person, room, and 
instruments when a ligature is employed that has been dragged 
over blankets or unclean tables before its introduction? when 
the wound is dusted with iodoform from a box that has been 
standing open, and has been used in all sorts of cases about 
a ward? when the operator rubs his nose, scratches his head, 
or touches nonsterilized objects, and introduces the hand into 
the abdominal cavity without precautionary cleansing? Such 
indiscretions are often responsible for stitch abscesses and 
other septic processes. Pus collections and cellular infiamma- 



854 GYNECOLOGY. 

tions in the pelvis in the region of the uterus frequently result 
from infection of serous collections in Douglas' pouch. Ele- 
vation of temperature, rapid pulse, and abdominal tender- 
ness subsequent to the fourth or fifth day should lead to care- 
ful exploration for their origin. A mass of exudate in the 
pelvis should be considered an indication for vaginal incision, 
for the administration of salines until free purgation is secured, 
and for the use of rectal and vaginal enemata of hot water 
at least twice daily. The vaginal incision should be a free 
one across the vault of the vagina, after which the cavity should 
be thoroughly irrigated with normal salt solution and a good 
packing of iodoform gauze introduced. This procedure should 
be preceded by careful sterilization of the vagina. 

653. Intestinal Complications. — In difficult operations in- 
flammatory intestinal sequels are not infrequent. The in- 
testines may be obstructed by twists, and this danger is ag- 
gravated by bands of inflammatory adhesions, or by openings 
in the omentum or mesentery, through which a knuckle of 
intestine can slip and become strangulated. Lacerations of 
the intestinal coat affect the peristaltic action, and may lead 
to paralysis of a section, with ensuing symptoms of obstruction. 
A twist or volvulus may become so fixed that nothing will 
pass it. In walls that are already weakened a fecal fistula will 
result. In a case some years ago in the Philadelphia Hospital 
an operation by a colleague was followed five weeks later by 
symptoms of obstruction, and the patient vomited stercoraceous 
material. The abdomen was reopened and five feet of intestine 
were torn up, disclosing a distinct volvulus, which was untwisted, 
when the patient recovered after a prolonged convalescence. 
The importance of an early reopening of the abdomen in such 
a case can not be overestimated, as the obstruction may be 
due to strangulation of a knuckle of intestine beneath inflam- 
matory bands or to its inclosure between sutures of the wound. 
The latter is unlikely to occur when the wound is closed in the 
manner we have suggested. 

654. Causes of Death. — Causes of death after ovariotomy 
are, as in hysterectomy, shock, hemorrhage, and peritonitis. 
These sequels are much less infrequent, however, as the opera- 
tion for ovariotomy is more easily accomplished and the dura- 
tion is shorter than in hysterectomy. Tetanus, which former- 
ly occurred frequently after ovariotomy, is now extremely 
rare. Ileus may occur in the second week as a result of ad- 
hesions or twists of the intestine. Inability to accomplish 
the evacuation of the intestine by injections with the pelvis 
elevated, and especially when complicated with stercoraceous 
vomiting, should require the reopening of the abdomen. The 



OVARIAN TUMORS. 855 

mortality of ovariotomy is very slight — much less than formerly. 
This is partly due to the fact that operations are now performed 
early, and it is only in rare instances that the patients are sub- 
ject to the deleterious action of the cyst. Early operation, 
before the patient experiences complications, is attended with 
very slight mortality. Thus, Martin in more than looo ovari- 
otomies has but 2 per cent, mortality; Olshausen reported his 
last loo ovariotomies with only 4 deaths. The uncomplicated 
ovariotomy has practically no mortality. 



LIST OF AUTHORS QUOTED 



A. 

Abel, 57, 58, 60, 586 
Abrahams, R., 209 
Adams, 483 
Ahlfeld, 535 
Albarran, 590 
Alexander, 450, 483, 499 
Alquie, 483 
Amann, 693, 785 
Amussat, 191 
Andrews. 274 
Antal, 660 

Apostoli, III, 112, 113, 114, 115 
^ 645 

Aran, 3 84 
Arnold, 73 
d ' Arson val, 115 
Atlee, 649 
Auer, 698 
Auvard, 202, 683 



B. 

Baccelli, 346 

Baer, 50, 665 

Baker, 724 

Baldy, 451, 490 

Banciier, 587 

Bandler, 537 

Barbour, 131 

Bardenheuer, 230, 598, 739 

Barnes, 23, 24, 182, 547 

Barrows, 346 

Bartholin, 60, 129, 287, 289, 290, 

295' 309. 322, 574, 582 
Bassini, 485 
Baum, 206 
Bayle, 599 
Beatson, 104 
Beclard, 202 
Bensa, 598 
Bernhardt, 763 
Bernutz, 384 
Biegel, 611 
Billroth, 730, 731 
Bischoff, 273 
Bishop, E. Stanmore, 231, 232, 

658, 668, 673, 674, 675 
Bland, P. Brooke, 84 
Blau, 691, 700 
Bode, 597 



' Boeckman, 77 
I Bohmer, 57 

Bottini, 731 

Bouilly, 674 
! Bovee, 207, 493, 729, 733 
I Bozeman. 225 
i Braun, 723 
! Breisky, 300, 301 
i Bright, 24 
I Bullitt, 796 

Burnham, 663 

Burrage, 469, 495 
644, Byrne, 117, 723,^34 



I Calderini, 731 

I Camero, 328 
Carlo, 817 

I Cassati, 485 
Chadwick, 28 

' Chantreuil, 721 
Cheston, 547 
Chrobak. 762, 764 
Churchill, 107, 214 
Clark, J. C, 95, 152, 
Cleveland, 270 
Cohnheim, 610 
Cohnstein, 721 
Colpe, 339 
Coover, E. H., 103 



292 



602, 



327. 409, 733- 740 
704, 778, 814 



Coplin, 56, 62 
Corneuil, 356 
Corradi, 731 
Corson, E. R., 227 
Courty, 22, 24, 25, 509 
Cowper, 129, 296 
Cox, S. E., 582 
Crede, 739 
Cucca, 763 
Cvillen, 691, 702 
Cumston, 767 
Curran, 207 

Czerny, 725, 729, 730, 732, 734, 749, 
752 



D. 



DaCosta, John C, 587 
Davidson, 74, 215 
Depage, 188 
Deschamps, 413, 724 



857 



858 



LIST OF AUTHORS QUOTED. 



DeSmety, i45. 337. 348, 355 

Doderlein, 305, 331, 574 

Doleris, 485 

Doran, Alban, 791, 792, 798, 812 

Douglas, 161, 163, 373, 398, 399, 401, 
407, 469, 500, 510, 512, 514, 515, 
516, 527, 553, 569, 587, 622, 657, 
658, 665, 666, 669, 670, 671, 673, 
699, 708, 723, 724, 731, 734, 736, 

737. 739. 745, 746, 749, 751, S15, 854 
Downes, A. J,, 417, 846, 847 
Doyen, 658, 671, 673, 675, 677, 731, 

r.7S9 ^ 

Drszewczky, 767 

Dudley, A. P., 271, 282, 489 

Dudley, E. C, 452, 467, 499, 668 

Duhrssen, 495, 732 

Duke, A., 279 

Duncan, Matthews, 384 

Dunning, 194, 352, 559, 566 

Duret, 485 

Duverney, 295 

Dybowski, 691, 702 



Eastman, Joseph, 414, 736, 739 
Edebohls, 29, 47, 51, 96, 216, ;^6^, 

485, 650 
Ehler, 761 
Ehrlich, 61 
Eiselsberg, 590 
Ellinger, 50 
Emmet, T. A., 105, 216, 238, 266, 269, 

282, 283, 338, 362, 393, 449 
Etheridge, 762 



Farre, 149 

Fehling, 752 

Fen wick, 815 

Ferguson, 42, 231, 232 

Ferguson, A. H., 450, 490, 499 

Ferraresi, 188 

Finsen, 117 

Fisher, J. M., 550, 554 

Flemming, 56 

Flick, 320 

Fowler, 100 

Fraipont, 762 

Franck, 734 

Frankel, 761 

Freund, W, A., 265, 386, 450, 496, 500, 

725, 737, 738, 739, 743, 767 
Fritsch, 278, 310, 594, 731, 752, 759, 

761, 765 
Frommel, 708, 734, 737, 751, 752 
Furbringer, 78 



Gabbett, 64, 321 
Gant, 157 
Gariel, 225 



G. 



Garrigues, 260, 449 

Gartner, 153, 575, 5^6 

Gehrung, 444, 644 

Gersterberg, 523 

Gessner, 778 

Gilliam, 490 

Goldman, 690 

Goldspohn, 487 

Gooch, 355 

Goodell, 24, 43, 44, 50. 762 

Gottschalk, 496, 656 

Gow, 664 

von Grafenberg, 722 

Gram, 60, 61, 298 

Greenhalg, 559 

Gremlier, 587 

Grenach, 56 

Gross, 494 

Griibler, 59 

Gubarroff, 739 

Guerin, 171 

Guinard, 762 

Guiteras, Ramon, 294 

Gusserow, 602, 611, 705, 710, 777, 779 

Guthrie, 153 

Guy on, 327 

H. 

von Hacker, 8^ 

Haeser, 80 

Hagedorn, 665 

Haine, 80 

Hare, Hobart A., 99, 681 

Harris, 66, 274, 320, 329 

Hart, 131 

Hauck, 664 

Haughey, 96, 10 1 

Hegar, 76, 260, 303, 449, 588, 646, 658, 

723. 724, 725, 748, 830 
Heidenhain, 754 
Heinecke, 748 
Heller, 300 
Hennig, 149 
Heppner, 264 
Herman, G. E., 157, 721 
Hermann, 56 
Herr, 238 

Herzfeld, 746, 747, 749 
Hewitt, Grailey, 444 
Hicks, Braxton, 559 
Higbee, 43, 44 
Hildebrandt, 263, 302 
Hirst, 511 

Hochenegg, 744, 747, 749, 750 
Hodge, Lenox, 478, 480, 485 
Hofmeier, 600, 611, 660, 705. 754 
Holden, 577 
Hollander, 188 
Houston, 157 
Houzel, 764 
Howe, 207 
Hugier, 129 
Hunter, 600 



LIST OF AUTHORS QUOTED, 



859 



Jacobi, 494 

Jacobs, 413, 691 

James, 559 

Johnson, J. Tabor, 599 

Johnstone, 177 

Jones, Mary Dixon, 806, 813, 814 

Joulin. 559 

JuUen, 316 

Jung, 56 



Kahlden, 778, 792 

Kaltenbach, 732, 736, 753 

Kappes, 390 

Kehrer, 764 

Keith, 92, 100, 405, 681, 847 

Kellar, 785 

Kellogg, 644 

Kelly, Howard, 65, 66, 78, 327, 491 

666, 667, 675, 731, 733, 740, 841 
King, 560 
Kiwisch, 355 
Klebs, 586, 597, 704 
Klob, 355, 599, 791, 795 
Kobelt, 129, 812 
Koberle, 663, 734 
Kocher, 748 
Konig, 163 
Koppe, 574 
Kraske, 586, 744 
Kronig, 305, 662 
Krusen, 535 
Kuchenmeister, 52 
Kuhn, 739 
Kummel, 812 
Kiister, 606 
Kiistner, 510, 744, 817 



L. 

Labarraque, 82 

Landau, 241, 419, 657, 705, 789 

Langenbeck, 729, 734 

Lauenstein, 139, 227, 245, 254, 263, 

279 
LeBec, 665 
Le Clerc-Dauday, 328 
Lefour, 634 
Lembert, 409, 665 
Leopold, 171, 611, 730, 753, 754, 755, 

762, 813, 839 
Levy, 748 
Lewers, 705, 791 
Lieberkiihn, 157, 159 
Liebmann, 732 
Limbeck, 693 
Lindfors, 494 
Lisfranc, 20 
Lugol, 61, 62 
Luschka, 138, 149, 162 
Lutaud. ^26 



I M. 

! Mackenrodt, 495, 731, 733, 734, 742, 

! 754 

i Maguire, 346 

Mann, 328, 488, 496, 613, 640 

Marchand, 770, 771 

Marcy, 510, 664 

Maritan, 796 

Marmorek, 345 

Mars, 300 

Marsh, 326 

Martin, A., 265, 273, 301, 339, 587, 
661, 669, 739, 763, 765, 767, 779, 855 

Martin, C, 175, 670 

Martin, Franklin, iii, 485, 642, 656 

Maydl, 751 

McBurney, 328 

McCosh, 409 

McGannon, 229 

Menge, 305, 306, 662, 742 

Mickwitz, 817 

Mikulicz, 94, 730 

Mitchell, S. Weir, 365, 383 

MoUer, 611, 612 

Monsell, 294 

Morgagni, 153, 157, 790, 796, 798 

Mosetig-Moorhof, 763 

Miiller, 118, 119, 181, 183, 188, 189, 
193. 283, 535, 546, 586, 716, 796, 798 

Miiller, Peter, 599, 731 

Munde, 444, 478 

Murphy, 852 

N. 

Naboth, ss, 145, 213, 214, 332, 338, 

466, 717, 718 
Napier, 177 
Nauss, 634 
Neisser, 60, 306 
Nelson, 43 
Netigebauer, 586 
Newman. 485, 735 
Nilson, 76 

Noble, Charles P., 268, 452 
Noble, Geo. H., 278 
Noeggerath, 355 
Nott, 43 
Nourse, 467 
Nuck, 121, 130. 189, 297, 574 



O. 

O'Hara, 852 

Olshausen, 491, 494, 611, 730, 731, 73 

752,836,837 
Orth, 58 
Outerbridge, 269 



Paget, Sir James, 781 
Paquelin, 338, 594, 595, 596, 734, 740, 
762, 849 



860 



LIST OF AUTHORS QUOTED. 



Pean, 412, 657, 735 

Peter, 300 

Petit, 702 

Pfannenstiel, 773, 807, 839 

Pfliiger, 150, 188 

Pick, 55, 56, 771 

Plouquet, 810 

Poirier, 755 

Polk, 161, 640, 741 

Poupart, 130, 163, 170, 388, 389, 483, 

533. 561, 573 
Powell, S. D., 326 
Pozzi, 49, 83, 124, 185, 223, 713, 790, 

794 
Pratt, 51, 362 
Price, M., 545 
Pro wcho wnik , 535, 611 
Pryor, 496, 666, 675, 691, 752 



R. 

von Recklinghausen, 610, 789 

Reed, C. A. L., 469 

Reich, 732 

Rein, 174 

Reyburn, 705 

Riberts, 704 

Ricard, 761 

Richelot, 673, 734, 735 

Ricker, 778 

Ries, 490, 496, 691, 740 

Ristine, 277 

Ritchie, 790 

Robb, 73 

Robertson, 179, 560 

Robinson, 303 

Robinson, Byron, 660 

Rokitansky, 590, 791, 800 

Rontgen, 116, 117 

Rosenmuller, 148, 153, 794, 796, 798 

Royster, 208 

Ruge, 307, 348, 689, 776, 778, 839 

Rumpf, 740 

Rydygier, 660, 748 



S. 

Sanger, 66, 223, 238, 277, 283, 629, 

730. 753. 764, 790. 791. 793. 795 
Sanger-Barth, 790, 792 
Sauter-Recamier, 729 
Savage, 127, 132 
Saxonia, 179 
Scanzoni, 355, 362, 815 
Scarpa, 389 
Schaefer, 385 
Schaeffer, 114 
Schatz, 731, 737 
Schede, 241, 747, 750 
Schering, 56 
Schlange, 748 
Schleich, 87 
Schmidt, 495 



Schnabel, 810 

Schramm, 763 

Schroder, 140, 219, 353, 362, 600, 606, 

638, 660, 664, 707, 723, 724, 725, 

731. 732, 742, 782 
Schuchardt, 733 
Schiicking, 495, 596 
Schultze, 336, 386, 477, 480, 481, 763, 

839 
Schwartz, 699 
Schwarz, 704 
Seelig, 690, 725 
Seeligman, 298, 299, 789 
Segond, 413 
Semmelweis, 342 
Shober, John B., 641 
Shoemacher, 611 
von Siebold, 715 
Simon, 38, 47, 241, 282, 724 
Simon-Hegar, 258 
Simpson, Alexander, 278 
Simpson, Sir James Y., 39, 355, 559, 

640 
Simpson (New York) , 739 
Sims, Marion, 29, 31, 45, 47, 133, 214, 

225, 303> 335. 465, 475. 646, 736, 

744, 761 
Skene, 64, 117, 125, 153, 154, 311, 312, 

314, 575, 847 
Skoldberg, 338 
Skrobanski, 208 
Smith, Albert H., 444 
Smith, Gregg, 557 
Smith, Hey wood, 337 
Smyly, 716 
Snow-Beck, 356 
Spiegelberg, 717, 814 
Steinthal, 749 
Stiegel, 582 
Stilling, 763 
Stoltz, 448, 500 
Stratz, 7 13 
Sutton, J. Bland, 175, 569, 600, 791, 

810 



Taenzer, 59 

Tait, Lawson, 278, 283, 361, 659 
Talley, F. W., 43 
Tannen, 753 
von Tauffer, 730, 744 
von Teuffel, 732 
Thiersch, 704, 754, 763 
Thomas, 339, 444, 464, 478- 5io 
Thompson, 591 
Thorn, 753 
Thornton, 816 
Thure- Brandt, 109 
Tilt, 303 

Torgler, 760, 764 
Tratz, 587 

Trendelenburg, 29, 31, 406, 407, 594, 
665, 671, 673, 674, 738, 851 



LIST OF AUTHORS QUOTED. 



861 



Ttiffier. 87, 735 
Ttiholske, 536 
Tyson, 519 



Ungara, 763 
Unna, 60 



U. 



Van De Warker, 724, 760, 761 
Veit, 699, 732, 739, 772 
Vineberg, 496, 500 
Virchow, 355, 384, 590, 627, 704, 

715, 778, 805 
Vuliet, 52, 521, 763 



W. 

Walcher, 227 
Waldeyer, 149, 704 
Walsh, Jos., 320, 321 
Walthard, 305, 306 
Wassiljew, 598 



Watkins, 845 

Webster, 490, 557 

Wecchi, 731 

Weigert, 59 

Weil, 664, 779 

Wells, Spencer, 70 

Werder, X. O., 241, 740 

Wertheim, 61, 496, 749 

Westermark, 744 

Widal, 342 

Williams, C. Rogers, 693 

Williams, J. Whitridge, 778 

von Winckel, 188, 600, 611, 634, 705, 

706, 713, 732, 750 
Wmter, A., 693, 699, 734, 754, 755 
Wisselinck, 752 
Wolf, 586 
Wolffler, 748 
Wylie, W. Gill, 488, 496 



Z. 

Zwank, 444 

Zweifel, 307, 664, 737, 749, 768, 789 



NDEX 



Abdominal binder, 360 

examination, 67 

section, 83 

assistants in, 88 
details of procedure, 406 
site of incision, 90 
Abortion, 539, 822 

tubal, 539, 542 
Abscess about appendix, 27 

collection in pelvis from appendix 
398 

from Bartholin's gland, 295 

intraperitoneal, 396 

stitch, 726 

vulvar, 294, 297 
Accidents and results of fistula opera 

tions, 243 
Acetanilid, 102, 108, 681 
Acetylene, 762 
Acid, boric, 105, 310, 5S6, 759 

carbolic, 74, 105, 293, 299, 310, 337 
354, 580, 664, 762 

chromic, 108, t,t,'] , 353, 578 

gallic, 519, 522, 640 

hydrochloric, 108 

hydrocyanic, 299, 316 

lactic, 339 

muriatic, 75 

nitrate of mercury, loS, 337, 354 

nitric, 108, 57S, 762 
fuming, 106, 353 

oxalic, 75, 326 

pyroligneus, 214, 765 

salicylic, 315, 339, 586, 763 
and pepsin, 763 

sublimate, 105 

sulphuric, 108, 522, 640 
dilute, 68 2 

tannic, 107, 519, 522 
Acne, 289 

Adenoma malignum, 689 
Adenomas of uterus, 571 
Adenomatous cysts, 806 
Adenomyoma, 789 
Adenosarcoma, 777 
Adhesions, 91, 678 

in displaced uteri, 476, 487 

in ovarian tumors, 817, 819 

indication of malignancy, 837 



j Adhesions of abdominal tumors, 834, 
! 841 

vascular, 91 
Adipocere, 547 
Adnexa, suppurative inflammation of, 

114 
Adrenalin, 104 
Agents, various local, 107 
Albumin in cyst contents, 808 

peptone, 808 
Albuminuria, 816 
Alcohol, 77, 293, 299, 646, 730, 763 

absolute, 730, 763 

dilute, 597 
Alcoholic preparations, 87 
Alexander operation, 483 
advantages of, 486 
disadvantages of, 486 
Alkaline solutions, 294 

waters, 309, 325, 361 
Alteratives, 102, 108 
Alum, 108, 522 

and sugar, 578 
Amenorrhea, iii, 114, 176, 287, 357, 

379, 615, 620, 622, 817, 831 
Aminoform, 325 
Ammonium benzoate, 326 

chlorid, 102 

salts. 640 
Amputation of the cervix, 218, 446, 

723 
Amyl nitrite, 71 
Anal ulcerations or fissures, 32 
Anastomosis of intestine for gangrene, 
850 
for injury, 85 2 
of ureter with bladder through ab- 
domen, 242 
through vagina, 240 
Anatomy and embryology of the 
genito-urinary organs of the woman, 
118 
Androgyna, 202 
Anemia, 21 

Anesthesia, administration, ^6 
agents employed in, 84 
bromid of ethyl, 84 
chlorid of ethyl, 84 
chloroform, 84, 85 
and oxvgen, 86 
ether, 84' 
863 



864 



INDEX. 



Anesthesia, agents employed, nitrous 
oxid gas, 84 
artificial respiration in, 86 
contraindications to, 86 
indications for, 84 
local, agents employed in, cocain, 
86, 579 
freezing, 86 
infiltration, 87 
nervous, 21 
spinal, Sj 
Angiosarcoma, 777 
Angiotribe, 672, 735 
Anodynes, loi, 108, 681 
Anorexia, 766 
Ano vulvar fistula, 246 
Anteflexion of uterus, 459 
cellulitis a cause, 461 
diagnosis, 462 

differential from myoma, 462 

rectal palpation in, 463 
etiology, 461 
immobile, 460 
indifferent, 461 
mobile, 460 
pathologic, 461 
physiologic, 461 
symptoms, 462 
treatment, 463 
bougies, 465 
laminaria tents, 464 
operative methods, 465, 466 
Anteposition of uterus, 453 
Ante version of uterus, 454 
diagnosis, 455 
etiology, 455 
symptoms, 455 
treatment, 456 
cincture, 457 

dilatation and curetment, 456 
hot douches, 456 
massage, 457 
Sims' operation, 456 
Antipyretics, 393, 765 
Antipyrin, 766 
Antisepsis, 72 

of cervix and uterine cavity, 82 
Antiseptics, 108, 294 
Antispasmodics, 103 
Anus, anatomy of, 157 

columns of Morgagni, 157 
sinuses of Morgagni, 157 
artificial, 737, 751 
fissure of, from pressure of uterus, 

459 
orifice of, 157 
Aperients. 404 
Apiol, 104 

Aponeurosis, union of, 96 
Apoplexy of the ovary, 152 

ovarian, 517 
Appendages, displacements of, 512 
diagnosis, 515 



Appendages, displacement of, symp- 
toms, 514 
treatment, 516 
instrumental, 516 
operative, 516 
Appendiceal inflammation, 68 
Appendicitis a frequent cause of peri- 
tonitis, 398 
catarrhal, 328 
Appendix vesiculosa, 153 
x\pplications, antiseptic, 107 
astringents, 107 
blisters, 106 
caustic, 107 
counterirritants, 106 
croton oil, 106 
ice-bag, 106 
local, 106 
tinct. iodin, 107 
various agents, 107 
carbolic acid, 107 
Churchill's tincture, 107 
creasote, 107 
iodoform, 108 
nitrate of silver, 108 
nitric acid, 108 
Arbor vitse, 145 
Areolar cysts, 806 
Aristol, 82, 765 

Arrangement for operation, 88 
Arsenic, 103, 303, 361 
Artery, azygos vaginae, 164 
circular, of cervix, 164 
inferior hemorrhoidal, 166 
internal iliac, 164 
internal pudic, 164 
middle hemorrhoidal, 164 
of bulb, 166 
of clitoris, 166 
ovarian, 163 
puerperal, 163 
superficial perineal, 166 
transverse perineal, 166 
uterine, 164 
vaginal, 164 
Artificial heat, care in use of, 99, loi 
Asafetida, 103, 180 
Ascarides sca'biei, 299 
Ascites, 608, 629, 809, 816, 822, 824, 

837 
Asepsis, 72 
Aspiration, 71, 72 
Aspirator, 71 
Assistants, S^, 841 

operator and, 78, 841 
Astringent douches, 105 
Astringents, 108, Tf^y, 482, 519, 522, 

593. 597. 764 
Atmocausis, 523 
Atresia, acquired, 194, 221 

congenital, 194 

diagnosis of, 195 

influence on menstruation, 195 



INDEX 



865 



Atresia, lateral, 197 
treatment of, 197 
of cervix, 353 
of genital canal, 194 
of one horn of uterus, 185 
of tirethra and vagina, 203 
site of occurrence of, 194 
symptoms and signs of, 194, 195 
vaginal, 221 
vulvar, 194 

Atropin, 85, 98, 345, 680, 848 

Autoinfection, 305 



B. 

Bacilli coli communis, 63, 286, 395 
Bacillus of cocain, 316 

tuberculosis, 63, 286, 318, 320 
Bacteriologic cultures, 60 

bacilli coli communis, 63 

bacillus tuberculosis, 63 

gonococcus, 60 

staphylococcus pyogenes aureus, 
62 

streptococcus pyogenes, 62 
Balloon, rubber, for vesical disease, 

327 
Bandages, elastic, 443 
Barium platinocj'^anid, 116 
Bartholinitis, 295 

diagnosis, 297 

treatment, 297 
Bartholin's gland, 295 

description of, 129 
Baths, 105 

cold hip, 360 

hot sand, 498 

medicated, 361 

peat, 498 

sitz, 105, 498, 764 
Battery, electric, 112 
Bed-sores, 765 
Belladonna, 325 
Benzoate of ammonium, 326 
Bicycle, 104 
Bifidities, 181 

degrees of division, 181 
Bimanual procedure, 35 
Bischoff's dissection, 273 
Bismuth salve, 765 

subnitrate, 317 
Bladder, 154 

anatomy of, 154 

bas-fond of, 154 

catheterization of, 66 
double catheter in, 66 

dissected from cervix in vesico- 
uterine fistulae, 238 

divisions of, 154 
* duplication of, 206 

exploration of urethra, ureters and, 

64 
exstrophy of, 198, 203 

55 



Bladder, extension of cancer to, 695, 
696, 700 
inflammation of neck of, treatment, 

.325 
injury to, during operation, 853 
irrigation of, 518 
mucous membrane of, 155 
position of, 154 
trigone of, 154 
tumors of, 590 

carcinoma, 597, 696 
symptoms of, 597 

of villous tumors simulated 
by uterine cancer, 598 
treatment of, 598 
dermoid. 591 
myomata, 591 
cystic, 591 
diagnosis of, 592 

differential, between renal 
and vesical hemorrhage, 

. 593 
significance of character of, 
hemorrhage in, 592 
hard, 591 
symptoms of. 591 
anemia. 592 
cachexia, 592 
cystitis, 592 
emaciation, 592 
hemorrhage, 591 
pain, 592 
treatment of, 593 

incision, abdominal, 594 
high bladder, 594 
suprapubic transverse, 594 
vaginal, 593 
operation, the, 593 

means of controlling hem- 
orrhage in, 595 
removal through urethra, 

593 
polypi, mucous, 591 

villous. 590 
total extirpation of, 598 
Blastoma, 770 
Blister, 106, 380 
Blood, examination of, 80 
Bloodletting, 106 
Borax, 108 
Boric acid, 105 
Boroglycerid, 109, 215 
Bougies, Hegar's, 646 
in the ureters, 740 
Brandy. 405 

Broad ligaments, 159, 793 
cysts of, 71, 793 
echinococcus, 794 
parovarian, 794, 811 
defects of round or, 189 
fibroma of, 795 

confounded with epiplocele, 795 
with fatty hernia, 795 



866 



INDEX. 



Broad ligaments, fibroma of, con- 
founded with ovarian hernia, 

795 
lipomata of, 795 
malignant growths of, 795 
parovarian varicocele, phlebo- 
liths, 795 
Bromid salts, 103, 326 

of ethyl, 84 
Buboes, 585 
Buchu, 326 
Bulb of the vestibule, 129 

of the ovary, 169 
Bulbocavernosus muscle, 127, 153, 303 



Cachexia, 617, 618, 779, 781, 837 
Cesarean section, 767 
Caffein citrate, 681 
Calcium carbid, 762 
chlorid, 640 
tungstate, 116 
Calculi and concretions following fis- 
tula operations, 245 
Calculus, renal, 433, 519, 821 
passage of, 313 
uterine, 626 
Calomel, 102, 317, 405, 682 

and sodii bicarb., 100 
Camphor, 316, 597 
Canal of Nuck, 130, 189, 574 
Cancer of uterus, 598 
Cannabis indica, 640 
extract, 639, 640 
fluid extract, 103 
tincture, 299 
Cannula, glass, 81 
Carbohydrates, 640 
Carbolic acid, 74, 105, 293, 299, 316, 

337' 353. 580, 646,^762 
Carbolized oil, 765 

Carcinoma, 597, 620, 628, 686, 791, 837 
adenomatosum, 689 
circumscribed, 697 
diffuse, 697 

of bladder and ureters, 597, 696 
of Fallopian tube, 791 
of ovary, 699, 814 
of uterus, 686 
body, 696 
cervix, 693 

adenocarcinoma of, 693 
methods of development, 694 

of extension, 694 
pathology of, 686 

cauliflower growth, 692 
clinical forms, 702 
involvement of bladder and 
ureters, 696 
of other organs, 695 
multiple epitheliomata, 699 
process of extension, 699 



Carcinoma of uterus, cervix, pathology 
of, general, 686 
adenoma malignum, 689 
blood-vessels slow to be in- 
volved, 690 
cylinder cell, 687 
influence upon surrounding 

tissues, 698 
lymph-vessels principal route 

of extension, 690 
squamous cell, 686 
structure of stroma, 689 
complications of, 712 
myoma, 712 
ovarian tumors, 712 
periuterine inflammation, 712 
pregnancy, 712, 713 
diagnosis of, 714 
curet, 715 

differential, from chorioepithe- 
lioma, 718 
from chronic cervical catarrh 

with laceration, 716 
from necrosis of fibroid poly- 
pus, 716 
from papillary erosion, 716 
from partial retention of pro- 
ducts of conception, 716 
from sarcoma, 716 
from syphilitic ulceration, 
716 
laminaria tents, 715 
microscopic examination, 715 

test excision for, 715 
rectal examination, 716 
duration, 720 

of recovery, 752 
effect of, upon pregnancy and 
labor, 721 
pregnancy and labor upon, 721 
etiology, 704 

Cohnheim's theory, 704 

condition of life, 705 

heredity, 705 

Klebs' bacillus, 704 

origin from micro-organisms, 

704 
Ribert's theory, 704 
sex, 705 

sexual activity, 705 
Thiersch's theory, 705 
Virchow's theory, 704 
Waldeyer's theory, 704 
prognosis, 720 

symptoms and clinical course, 706 
cachexia, 706 

degeneration of kidney, 709 
dilated ureters, 708 
distention of hemorrhoidal 

veins, 709 
edema of lower extremities, 
709 
of vulva, 709 



INDEX. 



867 



Carcinoma, symptoms and clinical 
course, emaciation, 709 
hemorrhage, 706 
hydronephrosis, 708 
lung embolism, 710 
metastasis, 709 
obstruction of veins and 

arteries, 709 
offensive discharge, 707 
pain, 707 
pleurisy, 710 
pneumonia, 710 
sacculated kidney, 709 
sepsis, 709 
treatment, 722 
in labor, 768 

in pregnancy complicating, 767 
operation in, 767 

Caesarean section in, 767 
inoperable cases, 756 
caustics, 760 
cureting, 757 

danger and injuries in, 

759 
dry, 764 

gauze packing, 764 
local, 761, 762 
palliative operations, 764 
parenchymatous i n j e c - 

tions, 763 
suture cureted surface, 

763 

symptomatic, 764 

when disease far advanced, 

765 
with fistula of rectum and 
bladder, 765 
operable cases, 722 

extirpation, total, 725 
by hysterectomy, ab- 
dominal, 769 
catheterization of ure- 
ters for, 733 
clamp forceps in, 731, 

735 
control of hemorrhage 

in, 741 
Freund's operation, 

738 

in marked involve- 
ment of the cervix, 
740 

modifications of, 739 
by hysterectomy, va- 
ginal, 729 

accidents of, 736 

by perineal method, 

751 
by sacral method, 744 
comparative advan- 
tages of abdominal 
and vaginal routes, 
742 



Carcinoma, treatment, operable cases, 
total extirpation by 
vaginal hysterec- 
tomy, contraindica- 
tions to, 753 
control of bleeding 
vessels, 735 
of bleeding vessels 
by hot iron, 734 
deep vaginal incision 

.in, 732 
difficulties in, 732 
disposition of ovaries 

and tubes, 729 
injuries to bladder, 
. .736 
injuries to one or both 

ureters, 736 
injuries to rectum, 737 
modifications of, 739 
mortality of, 752 
nonemployment of 
forceps or ligatures, 

735 
Schuchardt's opera- 
tion, 733 
treatment of the 
wound in, 730 
possibilities of reinfec- 
tion, 726 
uncertainty of keeping 
outside the disease, 
726 
when it ma}^ be under- 
taken. 725 
partial operations, vaginal, 
722 
amputation of cervix 
with galvanocau- 
tery loop, 723 
Hegar's operation, 724 
Schroder's opera- 

tion, 724 
preliminary, 728 
recurrence, after opera- 
.tion, 753 
diagnosis of, 755 

extension to parame- 
trium, 754 
infection, 755 
lymph-gland, 754 
metastatic, 756 
lymph-glands source of 
♦ redevelopment, 755 

summar}', 768 

abdominal operation, 

769 
vaginal operation, 769 
Cardialgia, 660 

Caruncle, urethral, 32, 575, 584 
Carunculcfi myrtiformes, 127, 200 
Castor oil, 405 
Castration for myomata, 646, 658 



868 



INDEX. 



Castration, uterine, 646, 658 
Catarrh, chronic cervical, 331 
Catgut, 95, 96, 663, 847 
for Hgatures, 76 
juniper, 664 
Catheter, double, 66 
glass, 98 

precautions in use of, 311 
self-retaining, 311 
ureteral, 65 
Catheterization, 98, 592 

microbes introduced by, 318 
of the ureters, 65, 320, 518 
Caustics, 108, 757, 760 
acid carbolic, 108 
chromic, 108 
hydrochloric, 108 
nitrate of mercury, 108 
nitric, 108 
sulphuric, 108 
caustic iron, 108 

potash, 224 
chlorid of zinc, 108 
creasote, 108 
liquid, 108 
silver nitrate, to8 
Cauterization, 762 

for fistula, 224 
Cautery, galvano-. 593, 731, 734 
loop, 731 

Paquelin, 594, 734, 740 
thermo-, 731, 768 
Cellulitis, abscess from hypogastric 
glands, 386 
cause of anteversion. 455 

of atrophy of uterus and ovaries, 

386 
of dysmenorrhea and sterility, 386 
of lateral version, 459 
diagnosis, 390 
differential, 391 

hematoma of broad ligament, 

391 
myoma of uterus, 391 
pelvic peritonitis, 391 
division of, 385 
etiology of, 386 
pelvic parametritis or periuterine 

phlegmon, 384, 455, 519 
physical signs, 387 

abscess resulting from. 386 
diffuse pelvic suppuration, 390 
pathologic anteflexion, 386 
prognosis, 392 

duration and progress, 392 
symptoms, 387 
treatmenc of, 393 
diet, 393 

douches, hot vaginal, 393 
pelvic massage, 394 
preventive, 393 
surgical interference, 393 
utero-sacral, 386 



Cervix, amputation of, 218, 446 

after-treatment, 219 

double flap, 219 

for areolar hyperplasia, 334 

for bilateral laceration of, t,t,^ 

for follicular erosion of, 333 

single flap, 219 
areolar hyperplasia of, 334 
carcinoma of, 693 
changes of, 141 
chronic catarrh of, 331 
cystic degeneration of, 333 
divisions of, 140 

infravaginal, 140 

supravaginal, 140 
erosion of, 331 

follicular, 333 

granular, 332 

simple, 331 
hypertrophic elongation of, 428, 

• ^■■^•^ , 
incision or, 51 

complete bilateral, 52 

inflammation of, 331 

causes of, 334 

classification of, 330 

diagnosis, 335 

physical signs, 335 

prognosis, 336 

symptoms, 334 

treatment, 336 

constitutional, 336 

electrical, 339 

local, 336 

surgical, 339 

lacerations of, 211, 333 

diagnosis, 212 

symptoms, 212 

sarcoma of, 773 

split in vesico-uterine fistula, 238 

Chancre, 580, 584 

Chancroids, 294, 584 

Change of life, 178 

Charcoal in malignant disease, 586 

with iodoform, 764 

Chloral, 10 1, 681 

Chlorid of calcium, 640 

Chlorin water, 765 

Chloroform, 84, 85 

and oxygen, mixture of, 86 

in glycerin, 299 

Chlorosis, 21 

cause of delayed menstruation, 175 

Chorioepithelioma, 684, 686, 719, 770 

Churchill's tinct., 107, 214 

Cinchona, 361 

Cincture for anteversion, 457 

Cinnamon, tincture of, 522 

water, 682 

Clamp forceps, 731, 735 

objections to use of, 415, 789 

Richelot's. 734 

Clay pad electrode, 112 



INDEX. 



869 



Cleansing hands, 78 

Cleveland's suture in laceration of 

perineum, 270 
Climacteric, delayed, in fibroid 
growths, 636 
discharge following, 27 
entire removal of Fallopian tubes 
to establish, 659 
Clitoris, 121, 123 
anatomy of, 123 
bifid, 203 
defects of, 199 
hypertrophy of, 32, 199 

nervous phenomena produced by, 

199 
prepuce adherent to, 199 
treatment of, 199 
Cocain, 86, 304, 681 
Coccyx, resection of, for artificial anus. 

590 
Codein, 766 
Cod-liver oil, 361 
Coition, 19, 209, 212, 302 

a cause of inflammation, 285 

in diseased appendages, 514 

loss of sensation, 21 

painful, 514 
Cold pack, 103 
Colic, gall-stone, S3 5 

intestinal, 328, 835 

renal, 835 

uterine, 107 
Collapse, 822 

atropin in, 405 

digitalin in, 405 

external heat in, 405 

str3'chnin in, 405 
Collodion, 113 

Colloid contents of cysts, 837 
Colon, malignant disease of. 68 
Colotomy, 590 
Colpeurynter, 225, 739 
Colpitis, 304, 756 
Colpocleisis, 233, 744 

methods of procedure in, 233 

objections to, 234 . 
Colporrhaphy, anterior, resection of 
anterior vaginal wall for, 449 
Stolz's sutures in, 448 

posterior, 449 
Coma, 708 

Communications, abnormal, 206 
recto-vaginal, 206 
recto-vagino-vesical, 207 
suprapubic opening of vagina and 

urethra, 207 
vagino-rectal, 207 
vesico- vaginal, 207 
Commutator, 113 
Compresses, cold, 299 
Compression of the lung, 840 
Compressor urethrae, 153 
Condylomata of vulva, 578 



Connective tissue, distribution and re- 
lations, 162 
pelvic, 162 

two varieties of, 162 
Constipation, 22, 614 

with cancer, 766 
Copaiba, 316 
Copper, sulphate of, io8- 
Copremia, 23 
Copulation, 174. 180 
Corpus albicans, 152 
luteum, 151 
cysts of, 800 
of pregnancy. 152 
Cotton, absorbent, 108, 294 

pack, 310 
Counterirritants, 106, 362, 3S0 
Cowper's gland, 129 
Crayons, chlorid of zinc, 108 
iodoform. loS 
silver nitrate. 297 
sulphate of zinc. 108 
Creolin, 81, 105 
Croton oil, 106, 380 

mixture, 362 
Cubebs, 316 
Culdesac, utero-rectal, 160 

vesico-uterine, 160, 161 
Curet, 215, 716, 763 

perforation of uterus with, 211 
sharp, 758 
spoon, 763 
Cureting, 53, 456, 646 

method of, 646 
Cystadenoma, 836, 837 
Cystalgia, 320 
Cystitis,' 235, 317. 591, 592 
acute, 317, 518 

Liri 
constitutional disturbances in, 

318 
etiolog}^ of, 317 
symptoms of, 318 
chronic. 317, 319, 518 

condition of urine in, 319 
constitutional conditions in. 319 
diagnosis of, 320 

from administration of certain 

drugs, 318, 323 
from foreign bodies, 318, ^2^ 
cystotomy for, 328 
etiology of, 317 
hematuria in, 319 
symptoms of, 319 
membranous, 322 
causes of, 322 
symptoms of, 322 
of gonorrheal origin, 319, 322 
prognosis in, 323 
treatment of, 324 

calculi and foreign bodies, 326 



medical. 



324 



870 



INDEX. 



Cystitis, treatment of, prophylactic, 

324 
surgical, 327 
tubercular, 319 
Cystocele, 32, 252, 432, 587 
diagnosis of, 435 

treatment. See Colporrhaphy, an- 
terior. 
Cystoscope, electric, 65 
Cystoscopy, 593 
Cysts, adenomatous, 806 
areolar, 806 

of Bartholin's gland, 296 

treatment of, 297 
of broad ligament, 71, 789, 793, 
796 
echinococcus, 794 
dermoid of bladder, 591 
of Fallopian tube, 791 
of ovary, 796, 805, 810, 819 
glandular, 805, 815 
hydatid of Morgagni, 153 
intraligamentary, 802 
Nabothian, 332, 466, 717, 718 



D. 

Dartoid, 121 

Death after hysterectomy, 679 

after removal of large tumors, 851 
causes of, after hysterectomy. 679 
Deciduo-chorion cellulare, 770 
Dendritic growths, 809 
Dermoid cyst, 810, 820, 821 

diagnosis, 836 

of bladder, 591 

of Fallopian tube, 789 

of ovary, 796, 805, 810, 815, 819 
peritonitis from, 821 

rupture of, 821 
Descent or prolapsus of the ovary, 189 
Desmoid tumor of abdominal walls, 68, 

Desmopycnosis, 489 
Destructive bladder mole, 770 

placental polyp, 685, 770 
Deviations of the pelvic organs, 421 
Dextrofiexion, 496 
Diabetes mellitus, cause of vulvitis, 

289, 291, 293 
Diagnosis, 20 

cause of error in, 20 

importance of correct, 18 

method of procedure in, 20 

senses employed in, 28 
Diaphragm, pelvic, 132. See Perineal 

muscles. 
Diarrhea, 22, 822, 835 
Diet after operation, 99 

in pelvic cellulitis, 393 
Digitalin, 10 1, 345 
Digitalis, tincture of, 345 
Dilatation of the urethra, 64 



Dilatation of the uterus, -521, 646 
bloodless, 48, 50 
bougies, 521 
divulsion, 50 
gauze packing, 52, 521 
gradual, 50 
incision, 51 

bilateral, 52 
rupture of uterus by, 51 
tents, 48, 522 
Dilators, Hegar's, 646 

Pratt's, 51, 362 
Discharge, genital, 26 
catarrhal, 26 
cervical, 27 
effect of age upon, 27 
origin of, 26 
simulating abscess, 27 
sources of purulent , 2 7 
vaginal, 27 
Discus proligerus, 151 
Disease, origin of, 17 
Dislocations of uterus, 453 
anteposition, 453 
dangers of sound in, 454 
diagnosis, 454 
lateral position, 453 
retro-position, 453 
torsion, 426, 454 
Displacements of the appendages, 512 
diagnosis, 515 
symptoms, 514 
treatment, 516 
of the uterus, 425 
classification of, 425 

anteflexion, 426, 459 

antelocation, 426 

ante version, 426, 454 

ascent, 426 

descensus, or prolapsus, 428 

dextrofiexion, 496 

dextrolocation, 426 

dextroversion, 426 

retrofiexion, 426 

retrolocation, 426 

retroversion, 426 

sinistrofiexion, 426 

sinistrolocation, 426 

sinistro version, 426 
complications, 496 
conditions which cause, 424 
diagnosis of, 427 
digital examination in, 436 
prognosis, 497 
treatment, 497 

electricity, 498 

general, 497 

massage, 498 

mechanical measures, 498 

summary in, 499 
Diuresis, 835 

Diuretics in cancer of uterus, 766 
in gonorrheal and acute cystitis, 325 



INDEX. 



871 



Divulsion, uterine, 50 
Douche, 105, 464, 498, 523 

alkaline, 310 

antiseptic, 338 

astringent, 105, 310, 338, 522 

hot, 214, 338, 354, 3S0. 393, 498. 

523 

intrauterine, 344 

rectal, 105 

urethral, 315 

vaginal, 220, 224, 315, 380, 393, 

498. 523. 

vesical, 106 
Douglas, pouch of, 161 
Drain, gauze, 94, 406, 597 
where placed, 95 

Mikulicz, 94 
Drainage, 92, 655 

management of, 92 

objections to, 93 

postural, 95, 409 

tube, 92 
Dressing of wound, 96, 843 
Dressings, 77 
Dropsy, hepatic, 829 
Dudley's operation for prolapsus uteri, 

452 

denudation, 271 
Duke's operation, 279 
Dysmenorrhea, 24, 114, 115, 176, 351, 

357, 463, 616 
from obstruction of uterine canal, 

462 
Dyspareunia, 24, 302, 576 
Dvspnea from cvsts, puncture for, 

841 



Echinococcus cysts, 794, 837 
Ecraseur, wire, 512, 723 
Ectopia of bladder, 204 
Eczema of vulva, 289, 293, 298 

from carcinoma, 765 
Edema, malignant, 607 

of labium, 525 

of leg a symptom of cancer, 837 

of vulva, 295 

preliminary puncture of cvsts for, 
841 
Electricity, iii, 339, 498 

Apostoli's method, 112, 642 

apparatus for application, 112 

battery for, 113 

electrodes, 113 

faradic, iii, 114 

Finsen light, 117 

forms of , 1 1 1 

franklinic, iii 

galvanic, iii 

in fibroid growths, 641 

in lateral flexion, 498 

indications, 114 



Electricity, methods of procedure, 113 
Rontgenic, 11 1, 116 
sinusoidal, iii, 115 
Electrocautery and light, 117 
Electrode, bladder, 112, 642 
clay pad, 642 
insulated probe, 113, 642 
metal, 1 11, 113 
water, 642 
wet towel, 113, 642 
Electrolysis in ovarian growths, 838 
Elephantiasis of vulva, 580 
Elytritis, 304 
Elytrotomy, 559 
Embolism, 637, 680 
Embr\'olog\' and anatomy of the 
genito-urinarv organs of the woman, 
118 
Emmet's operation for complete lac- 
eration, 269 
for lacerated cervix in metritis, 

362 
on the perineum in relaxation of 
posterior vaginal wall, 266 
Enchondroma, 628 
Endocervicitis, 331 
symptoms of, 331 
Endometritis, 307, 330, 339, 455, 699 
acute, 339 
chronic, 348 
diagnosis of, 342 

discharge associated with, 336, 348 
vegetations of the mucous mem- 
brane, 348 
villous degeneration, 349 
exfoliative, 349 
fungosa, 349 
gonorrheal, 339-349 
hemorrhagic, 24 

influence of, upon conception, 351 
membranous, 349 
pathologic alterations, 339, 355 
prognosis, 344 

results of neglected cases, 352 
senile, 350 
symptoms of, 340 
treatment, 344 
caustics in, 353 
cureting, 353, 354 

contraindications for, 353 
dilatation with laminaria tents, 

353 
dramagem, 353 
hot vaginal douche, 354 
intrauterine injections, 354 
intravenous injections, 346 
irrigation with antiseptics, 353, 

354 
prophylactic, 353 
repair lacerations, 353 
scarification, 354 
tampons, 354 
varieties and source, 340 



872 



INDEX. 



Endometritis, virginal, 349 
Endometrium, tuberculosis of, 786 
Enema, quinin, whiskey, and water, 
100 
soapsuds, turpentine, and eggs, 100 
Enemata, 405, 498, 766, 788 
coffee, 10 1, 681 
glycerin, 404 

in intestinal distention, 405 
medicated, 106 
normal salt solution, 681 
peptonized milk, 681 
rectal, 105 
soap and water, 404 
stimulants, 10 1 
whiskey, 681 
Enterocele, vaginal, 297, 439 
Enteroptosis, how avoided, 500 
Epilepsy, 176, 358 
Epiplocele, 297, 795 
Episiostenosis, 233 
Epispadias, 203 

treatment of, 205 
Epithelial pearls, 582, 687 
Epithelioma of uterus, 687 
of vagina, 588 
of vulva, 582 
Erector clitoridis muscle ,127 
Ergot, 103, 360, 361, 522, 639 
Ergotin, 559 
Eruptions, vulvar, 32 
Erysipelas of the vulva, 291 
Ether, sulphuric, 362 
Ethyl bromid, 84 

chlorid, 84 
Eucalyptus, 302 

essence of, 586 
Examination, 28 

abdominal preliminaries, 28, 67 
aspiration, 71 
auscultation, 69, 824 
exploratory incision, 72, 838 

puncture, 70, 837 
inspection, 67, 824 
palpation, 68, 824 
difficulties in, 69 
percussion, 69, 824 
tapping, 70 
instrumental, 39 
precautions, 41 
probes, 39, 40 
Sims', 39 
whalebone, 39 
sound, 39 
speculum, 39 
tenaculum, 47 
double, 47 
microscope, 53 
material for, 54 
methods of, 54 
pelvic, 28, 32 

bimanual procedure, 35, 618 
difficulties of, 35 



Examination, pelvic, bimanual pro- 
cedure, precautions in, 38 
digital, 33, 35, 716 
in virgins, 36 
inspection, 32 
position of the patient, 29 
preliminaries, 28, 32 
rectal touch, 36, 757 

conjoined manipulation in, 37 
recto-abdominal, 37 
rectovaginal, 37 
recto-vagino-abdominal , 3 7 
recto- vesical, 37 
Simon's method, 38 
simple touch, 32 
Exercise, rest and, 104 
Exophthalmic goitre, 640 
Exploration of tirethra, bladder, and 

ureters, 64 
Exstrophy of bladder, 198, 203 
Extract, belladonna, 325 
cannabis indica, 639, 640 
condurango, and vaselin, 767 
hamamelis, 640 
hydrastis canadensis, 640 
mammary gland, 641 
opium, 325 

thyroid gland, 103, 104, 522, 640 
Exudates, pelvic, 116 



F. 

Facies ovariana, 19, 816 

uterina, 22 
Fallopian tubes, 145, 148, 789 
absent or rudimentary, 188 
accessory ostia, 188 
adherent, 401 
anomalies in length, 188 
coats of, 146 
mucosa, 146 
muscular, 146 
serous, 146 
subserous, 146 
description of, 145 
divisions of, 145 
ampulla tubse , 146 
fimbriated extremity, 146 
infundibular tubse, 146 
isthmus tubas, 146 
ostium abdominale tubas, 146 
ostium uterini tubas, 145 
pars uterini, 145 
epithelium of, 147 
inflammation of, 365. See Sal- 
pingitis. 
length of, 145 
openings of, 146 
tumors of, benign, 789 

cysts of small size, 790 
dermoid, 790 
enchondromata, 790 
fibrocyst, 789 



INDEX. 



873 



Fallopian tubes, tumors of, benign, 
fibroma or myoma, 789 
papillomata, 791 
hydropic, 791 
simple cystic, 791 
polypus, 791 
malignant, 791 
carcinoma, 791 
chorioepithelioma, 793 
sarcoma, 792 
treatment of, 792 
Faradic current, 114, 365 
Farre, white line of, 149 
Fascia, anal, 130, 131 
deep, 310 

layer of superficial, 129 
obturator, 131 
pelvic, 131 
perineal, 129 
pyriform, 131 

relations to pelvic structures, 131 
superficial, 129, 130 
triangular ligament, 129, 130 
vesico-rectal, 130, 131 
Fecal fistula, 221 

incontinence, 251 
Fecundation, 174, 180 

union of spermatozoid and ovum, 
180 
Feeding, rectal, 6S2 
Ferri persulph., 519 
Fetal heart sounds, 70 
Fever, puerperal. 341 
Fibroid growths in the fundus a cause 
of anteversion, 455 
polypus, 604 
Fibroids, recurrent, 781 

sloughing, 83 
Fibroma of broad ligament, 795 
Fibromyoma of cervix, 609 
of ovary, 812 
of uterus, 599 
Fibromyomata, 599 
Fibrosarcoma, 777 
Fimbria ovarica, 146 
Finsen light ,117 
Fissure, anal, 23, 459, 470, 614 
vesico-urethral, 314 
appearance of, 314 
site of, 314 
Fistula, 23 
Fistulas , 221, 761 
causes of, 221 
cervical, 238 
classificaion of, 221 
fecal, 221 

ano-vulvar, 221, 246 

treatment, preliminary and 
after, 247 
entero-vaginal, 221, 247 
recto- vaginal, 221, 245 
genito-urinary, 221 
uretero-vasfinal, 221 



Fistulse, classification of, genito-urin- 
ary, urethro- vaginal, 221, 236 
utero-ureterine, 221 
vesico-uterine , 221, 236 
vesico-utero-vaginal, 238 
vesico-vaginal, 221, 225, 589 
intestinal, 699 
diagnosis of, 222 
etiology of, 221 
prognosis of, 223 
symptoms of, 222 
treatment, 224 

accidents and results of, 243 

calculi and concretions, 245 
hemorrhage, primary, after, 

243 
secondary, after, 243 
inclusion of ureters, 244 
peritonitis, 245 
after-, 233 

b}" cauterization, 224 
by colpocleisis, 233 

combined with recto-vaginal 

fistula, 236 
objections to, 236 
by denudation and stiture, 225 
by episiostenosis, 233 
by flap formation, 231 

advantages of, 232 
b}^ flap-splitting, 226 
by M^sterocleisis, 238 
by h^^sterostenosis, 238 
preliminary, 224 
uretero - vaginal - uretero - cervical, 

239 
treatment of, 240 

by anastomosis through the ab- 
domen, 242 
through the vagina, 240 
by nephrectom}", 243 
urethro-vaginal, 236 
vesico-uterine, 236 
vesico-uterovaginal, 238 
vesico-vaginal, treatment, 225 

Corson's method of flap-split- 
ting, 227 
denudation for, 225 
flap-formation, 231 
flap-splitting, 227 
flap-transplantation, 229, 230 
Flap operations, 231 
Flatus, rectal irrigation for, 788 
Flexion, anterior, of uterus, 459 
lateral, 496 
posterior, 469 
prognosis, 497 
treatment, 497 
electricity, 498 
massage, 498 

mechanical measures, 498, 499 
operative procedures, 499 
Follicular cysts, 799 
Fomentations, antiseptic, 293 



874 



INDEX. 



Fomentations, hot, 393, 405 

of lead water and laudanum, 293 
Forceps, 758 

Koeberle, 734 

pedicle, 563 

shovel, 734 
Formalin, 83 
Fornix, anterior vaginal, 134 

posterior vaginal, 134 
Fossa navicularis, 127 
Fourchet, 127 
Fowler's solution, 100 
Franklinism, 11 1 

Freund's denudation in laceration of 
perineum, 265 

operation for malignant disease, 737 
for shortening the utero-sacral 

ligaments, 496 
in marked prolapse, 450 
Friederichshall water, 102 
Fritsch's operation, 278 
Furuncle, 289, 297 



G. 

Gall-stone colic, 835 
Galvanic current, iii, 300, 303 
contraindications for, 114 
indications for, 114 
Galvanism, in 

apparatus for, in 

contraindications, 114 

in chronic endometritis, 112 

in fibroid tumors, 112 

indications, 114 
Galvano-cautery, 578 

loop, 731 
Galvanometer, 113 

Gangrene of fibromyomata of uterus, 
636 

of vulva, 295 
Gartner, canal of, 153 
Gauze, 74 

acetanilid, 82 

borated, 82, 215 

carbolized, 82, 215 

drain, 94, 406, 746, 749 

for dressings, 77 

for pledgets, 758 

formalized, 82 

iodoform, 82, 215, 760, 763 

pack, 52, 82, 92, 523, 525, 569, 655, 

671. 759. 770 
pads, 74, 280, 293, 408 
salicylated, 82 
sterilized, 82, 215 
sublimate, 82 
tampons, 108, 763 
thymolized, 215 
wick, 524 
Genital canal, atresia of, 194 

treatment of acquired, 195 
of congenital, 195 



Genital canal, laceration of, 248 
hemorrhage or bleeding, 519 
organs, 118 

development of, 118 
functions of, 174 

copulation, 121, 174, 180 
fecundation, 174, 180 
menstruation, 175 
nubility, 175 
parturition, 174 
puberty, 174 
malformations of, 181 
classification, 181 
acquired, 32, 181 
congenital, 32, i8i 
tumors, 571 
benign, 571 
definition of, 571 
difficulty of differential diag- 
nosis in, 571 
malignant, 571 
Genitalia, division of, 121 
external, 121 
internal, 133 
lymphatics of, 170 
Genito-urinary fistulse, 221 
organs, bifidities of, 181 
degrees of division of, 181 
development of, 118 
physiology of, 174 
tract, inflammation of the entire, 
283 
Gentian, compound tincture, 361 
Germinal epithelium, 149 
spot, 151 
vesicle, 151 
Germs, pyogenic, in discharge of uterine 

cancer, 742 
Gestation, 174 

ectopic, 517, 831, 835 
adipocere in, 547 
causes of, 533 
course and progress of, 537 
abortion, tubal, 539 
mesometric or intraligament- 

ary, 542 
moles, tubal, 539 
rupture, complete, 543 
incomplete, 543 
primary, 540 
secondary, 540, 545 
lithopedion, 546 
termination of, 546 
diagnosis, 549 
differential, 554 

from acute intestinal ob- 
struction, 557 
from fecal accumulation, 555 
from intraligamentary tu- 
mors, 555 
from ovarian tumors, 555 
from perforating ulcers in 
duodenum, 557 



INDEX. 



875 



Gestation, ectopic, differential diag- 
nosis from perforating 
ulcers in small intes- 
tine, 557 
in the stomach, 557 
in vermiform appendix, 

557 
from pregnancy, extrauterine 
with dead fetus, 557 
in one horn of bicomate 

uterus, 555 
spurious, 555 
uterine, 555 
from pregnant uterus, retro- 
flexed, 555 
from renal and biliary colic, 

557 
from rupture of pyosalpmx, 

557 
from strangulated hernia, i 

557 
from torsion of pedicle of 

small ovarian cyst, 557 
of tubal rupture, 557 
uterine tumors, 555 
lithopedion in, 546, 547 
macerated fetus, 554 
treatment of, 570 
mummification of fetus, 547 
pathological features of, 558 
prognosis, 558 
symptoms, 547 

discharge of decidual mem- 
branes, 548 
hematocele, anteuterine, 517 

circumuterine, 517 
hemorrhage, extraperitoneal, 

. 517 . 

intraperitoneal, 517 
secondary rupture, 540, 545 
treatment, 559 

electricity, 116, 559 
elytrotomy, 559 
evacuation of liquor amnii, 559 
four stages of operation, 561 
in rupture into broad ligament, 

564 
injection of poison into fetus, 

559 . 
operative, 561 

incision, abdominal, 562 

extirpation of entire sac, 

569 
removal of placenta 

without sac, 567 
Sutton's rules, 569 
three terminations, 567 
vaginal, 560 
varieties of, 535 
abdominal, 536 
tubal, 536 
tubo-ovarian, 536 
interstitial, 536 



Gland, Bartholin's, 129 

obturator, of Guerin, 171 
Glands, hypogastric or iliac, 170 
lumbar, 171 
lymphatic, 171 
sacral, 171 
Glandulse vestibulares minores, 153 
Glandular cyst, 801 
Glass plug, 191 
Gloves, rubber, 79 
Glycerin, 109 

on tampons, 498 
Glycerite of tannin, 109 
Gonococcus of Neisser, 60, 285, 290, 
308, 310 
examination for, 292 
ichthyol destructive to, 310 
Gonorrhea, 315, 791 

a cause of inflammation, 284, 285, 

2 86, 287, 2S9, 3 28, 349, 403 
more dangerous than syphilis, 286 
too frequently regarded unimpor- 
tant, 403 
Graafian follicles, 151 

corpus luteum of, 151 
nucleus of, 151 
Growths, fibroid, 455, 470, 496 
ovarian, 455, 496, 796 
retrouterine, cause for uterine 
ascent, 427 
Gynandria, 201 
Gynecolog}^ definition, 17 
difficulties in study of, 18 
theories of, 1 7 
value of notes in, 19 
Gyroma, 813 



H. 

Hamamelis, 103, 108, 361, 519, 522, 

639, 640 
Hands, preparation of, 78, 84 
Hearing, how utilized, 28 
Heart failure, 72 

sounds, fetal, 70 
Heat, artificial, 10 1 
Hegar's operation, 260 

modified, 260 
Hemorrhage, 24, 114, 287, 503, 559, 
675, 676, 679 
a symptom, 518, 527 
after removal of clamps, 789 
causes of, 24 
genital, 519 
causes, 519 
diagnosis, 520 
dilatation, 521 
with bougies, 521 
with dilators, 521 
with tents, 522 
importance of careful examina- 
tion in, 520 



876 



INDEX, 



Hemorrhage, genito-urinary, and ec- 
topic gestation, 517 
hematocele, 517 
diagnosis, 518 

differential, from rupture of 
pyosalpinx, 530 
from pelvic abscess, 530 
from retrofiexed gravid ute- 
rus, 530 
extraperitoneal, 517, 529 
intraperitoneal, 517, 526 

symptoms, 527 
pelvic, 397 

a cause of uterine ascent, 427 
a source of peritoneal inflam- 
mation, 397 
prognosis, 531 
symptoms, 529 
treatment, 531 

incision, abdominal, 532 

vaginal, 532 
ligation of bleeding vessel, 531 
hematocolpometra, 195 
hematocolpometrosalpinx, 195, 517 
hematocolpos, 195, 517 
hematoma, 395, 517, 586, 847 
ovarian, 152 

vaginal or thrombus, 524 
diagnosis, 525 

from pressure during labor 
upon an ovarian dermoid, 

525 
treatment, 525 
vulvar, 523 

diagnosis of, 525 

differential, from edema of 
labium, 525 
from labial tumors, 525 
during ovariotomy, 847 
treatment of, 525 
hematometra, 195, 517, 683, 762, 
779. 834 
unilateral, 322 
hematosalpinx, 195, 517, 761, 831 
hematuria, 517 
causes, 517 
in cystitis, 518 

tubercular, 321, 322 
in disease of ureter and pelvis of 

kidney, 518 
malarial, 518 
site and varieties, 517 
symptoms and diagnosis, 518 
treatment, 519 
astringents, 519 
operation, 519 
internal, loi, 287, 850 
menorrhagia, 517 
metrorrhagia, 517 
ovarian apoplexy, 517 

hematoma, 517 
periuterine, 526 
causes of, 526 



Hemorrhage, primary, after fistula 
operation, 243 
secondary, after fistula operation, 

243 

treatment, 522 

urinary, 517 
diagnosis, 518 
symptoms, 518 

uterine, thyroid extract in, 104 

vulvo- vaginal thrombus, 517 
Hemorrhoids, 22, 23, 37, 102, 298, 299, 
459, 614, 616, 617 

from pressure upon rectum, 459 
Hemostasis in ovariotomy, 736 
Heppner's method of suturing, 264 
Heredity, 612 
Hermaphroditism, 200 

androgyna, 202 

epispadias, 203 
treatment of, 205 

gynandria, 201 

hypospadias, 203 

pseudo-hermaphroditism, 200 
divisions of, 201 

true, 200 
Hernia, 130 

fatty, 795 

labial, anterior, 572 
posterior, 572 

ovarian, 795 

vaginal, 439 

ventral, 68, 825 
Herpes of the vulva, 291 
causes of, 291 
diagnosis of, 293 
Hildebrandt's denudation, 263 
History, method of securing, 19 
Hot fomentations, 393, 405 
Hottentot apron, 122, 199 
Hot-water bag, 325 

bottles, 680 
Houston, valve of, 157 
Hunyadi Janos water, 102 
Hydatid cysts of the uterus, 684 
of Morgagni, 153 

disease, 71 
Hydrarg. chlor. mit., 682 
Hydrastin, 103, 522, 640 
Hydrastinin, 103, 522, 640 
Hydrastis, 103, 108, 519, 522 

canadensis, 103, 317, 361, 640 
Hydrocele, 130, 297, 574 
Hydrogen peroxid, 82 
Hydrometra, 683, 834 
Hydronephrosis, 618, 685, 708, 837 
Hydrops folliculorum, 799 

tubse profluens, 27, 369, 801 
Hydrorrhea, 357, 358 
Hydrosalpinx, 369, 831 
Hydrotherapy, 105 
Hymen, 124 

annular, 126, 200 

anomalies of, 32 



INDEX. 



877 



Hymen, atresia of, 200 

biseptus or septus, 126, 200 

carunculse myrtiformes, 127, 200 

congenital absence of, 200 

crescentic, 124 

cribriform, 126, 200 

cysts of, 574 

defects of, 200 

falciform, 126 

imperforation of, 200 

incision of, 200 

infundibular, 126, 200 

labia-like, 126 

laceration of, 200 

linguaformis, 126 

rupture of, 126 

shape of, 200 

supernumerary, 200 
H3-peremia of the urethra, 311 

treatment, 315 
Hypodermocleisis of normal salt solu- 
tion for hemorrhage, 680, 851 
Hypospadias, 203 
Hysterectomy, abdominal, 769 

accidents during, 675 
hemorrhage, 675 
injuries of viscera, 676 
injury of intestine, 678 
of ureter, 677 

after-treatment, 680 

causes of death after, 679 

pan-, 669 

partial, 663 

vaginal, 657, 729 

by morcellement, 654 
description of operation, 657 
mortality of, 752 
Hysteria, 114, 358 

Hysterostenosis, or hysterocleisis, 238 
Hysterotome, 683 
Hysterotrachelorrhaphy, 216 



Ice suppositories, 533, 681 
Ice-bag, 106, 220, 325, 379, 393, 404, 
562, 594 

in dysmenorrhea, 106 
Ice-water irrigation, 758 
Ichthyol, 109, 215, 326 
Ileus, 680, 819, 835, 840, 854 
Incision, abdominal, 90, 843 

exploratory, 72, 838 

length of, 91 

ovoid, 731 

vaginal, for tumors of the bladder, 

593 
Infection, 32, 72, 284, 305, 312, 313, 

318, 319, 322, 339, 340, 395, 396, 

398, 630, 725, 726 
gonorrheal, 312, 319, 334 
how favored, 339 
localized points of, 347 



Infection, ovarian, 395 
specific, 306, 314 
streptococcic, 305 
Inflammation, 283 
acute, 285 

causes of, 285 
etiology of, 317 
gonorrhea and traumatism 

most prolific, 286 
micro-organisms as a cause, 284 
symptoms of, 287 
discharge, 308 

disturbances of menstruation, 
287 
and suppuration of cyst, S20 
appendiceal, 68 
characteristics of, 286 
chronic, no, 284 
classification of, 287 
exacerbations in, 286 
follicular, of urethra, 312 
immunity against, how lost, 284 
natural protection against, 284 
of bladder, 317 
acute, 318 

symptoms of, 318 
chronic, 319 

symptoms of, 319 
of cervix and body of uterus, 330 
of entire genito-urinary tract, 283 
of Fallopian tube, 365 
diagnosis, 372 
prognosis, 374 
symptoms, 371 
treatment, see Sec. 390 
of ovary, 374 
diagnosis, 379 
symptoms, 378 
treatment, 379 
of peritoneum, acute, 394 
adhesive, 398 
chronic, 399 
serous, 398 
suppurative, 398 
of ureter, 328 
of urethra, 310 

treatment, 315, 316 
of vagina. See Vaginitis. 
of vulva. See Vulvitis. 
pelvic, 384 



erroneous 



views of. 384 



peritonitis, parametritis, perisal- 
pingitis, and perioophoritis. 
See Pelvic peritonitis . 
varieties of, 284, 384 
acute, 284, 385 
chronic, 114, 385 
circumscribed, 285 
diffused, 284 
periuterine, 115 
Injections, bovinine, 682 
carbolized water, 316 
chlorid of sodium and sublimate, 763 



878 



INDEX. 



Injections, colored fluid in fistulae, 223 
deodorizing, 82 
disinfectant, 82 
hot vaginal, 299 

hydrogen peroxid and thymol, 765 
hypodermic, absolute alcohol, 763 
adrenalin chlorid, loi, 345, 680 
atropin, loi, 345, 680 
cocain hydrochlorate, 325 
digitalin, 10 1, 345, 680 
morphin, 10 1, 325, 680 
pyoktanin, 763 
salicylic acid and alcohol, 763 
strychnin, loi, 345, 680, 682, 842, 

848 
testicular fluid, 10 1 
intra-intestinal, 409 
intrauterine, 82 

intravenous, of normal salt solution, 
346, 406, 680 
corrosive sublimate, 346 
lime-water, 299 
milk, 222 

perchlorid of iron, 523, 641 
permanganate of potash, 765 
quassia, 299 

quinin, whiskey, and water, in in- 
testinal distention, 405 
silver nitrate, 316, 763 
sublimate, 299, 316 
tincture of iodin, 641 
vinegar-water, 641 
zinc chlorid, 316 
Inspection, 32, 67 
Instruments for ovariotomy, 841 
Internal hemorrhage, 835 
Interstitial, mural, or centric fibroid 

growths of the uterus, 606 
Interureteric ligament, 156 
Intestinal catarrh, 114 
complications, 851 
perforations, 395 
Intestine, injury to, during operation, 
678, 851 
kinking of, 679 
Intraligamentary cysts, 802, 816, 817 
Intrauterine douches, 344 
Inunctions of mercury and potassium 

iodid, 559 
Inversion of the uterus, 500, 620, 622 
and complications, 502 
degrees, 500 

extra-vaginal, 501 
intrauterine, 501 
intravaginal, 501 
invagination, 501 
diagnosis of, 504 

differential, from fibroid tu- 
mors, 506 
etiology, 502 

nonpuerperal, 502 
puerperal, 502 
symptoms, 503 



Inversion of the uterus, treatment, 507 
instrumental, 507 
operative, 507 

incision of vagina and pos- 
terior uterine wall, 510 
taxis, 507 
central, 509 
lateral, 509 
peripheral, 509 
Thomas operation, 510 
Iodin and carbolic acid, 363 
and perchlorid of iron, 363 
compound tincture of, 294 
tincture, 106, 107, 337, 353, 380, 
641, 648 
Iodoform, 82, 107, 108, 363, 586, 646, 
648, 764 
and charcoal, 585 
gauze tampons, 82, 108, 764 
pencils, 108 
poisonous effects of, 82 
lodol, 82 

Iron, 103, 336, 362 
perchlorid, 523 
persulphate, 519, 522, 579 
tincture of chlorid of, 108 
Irrigating tubes, 81 
Irrigation, 92, 647, 765 
continued, 79 

in suppurative peritonitis, 409 
vaginal, 80, 102 
with antiseptics, 765 
Ischioperineal ligament, 130 



J. 



Judgment, exercise of, 19 



K. 

Kidneys, amyloid degeneration of, 709 
disease of, 298 
sacculation of, 618, 701 _ 

associated with uterine cancer, 
709 
Kobelt's tubules, 812 
Koch's bacillus, 320 
Kraurosis vulvae, 300 

causes of, 301 

diagnosis of, 301 

division of, 300 

pathology of, 300 

prognosis of, 301 

symptoms, 301 

treatment, 301 
Kreatinin in cysts, 838 



L. 

Labia major a, 121 

agglutination of, 194 
anatomy, 121 
tumors of, 32 



INDEX 



879 



Labia minora, 121 
anatomy of, 121 

elongation and thickening of, 32 
Lacerations of cervix, 211 
diagnosis, 212 
symptoms, 212 
treatment, 214 
after-, 219 

amputation of cervix, 218 
preliminary ,214 
trachelorrhaphy, 216 
of pelvic floor, 248 
causes, 249 
degree or extent, 250 
operation for complete, 269, 
277 
for incomplete, 273 
after-treatment, 280 
choice of operation in, 282 
intermediate operation,2 55 
primar^^ operation, 253 
advantages of, 254 
contraindications, 255 
secondary operation, 256 
results, 251 
of sphincter ani, 249, 251, 254, 269 
of vagina, 220 
Lactation prolonged to avoid con- 
ception, 178 
Lauenstein's method of suturing, 263, 

279 
Laxatives, 102, 788 
Lead acetate, 105 
Lead-water and laudanum, 760 
Leucin in cysts, 838 
Leukorrhea, 19, 22, 26, 212, 305, 334, 

350, 357.' 35^. 379. 459. 57S, 
660 

in cervical inflammation, 334 

sources of, 26 

substitute for menses, 459 

symptom of metritis, 357 

with submucous growths, 615 
Levator ani muscle, 127, 130, 132, 249. 

254, 262.^524 
Lieberkiihn's crypts, 157 

folUcles, 159 
Ligament, broad, 421 

infundibulo-pelvic, 146. 159, 514, 
516 

interureteric. 156 

ischioperineal, 130 

of uterus ,173 

ovarian, 148 

Poupart's, 130 

pubo-vesical , 154 

round, defects of, 189 

triangular, 130 

uterosacral, 173, 421, 450, 453. 479, 

495 
uterovesical, 173, 421 
Ligature and suture material, 76 
catgut, 76, 664, 847 



! Ligature and suture material, parti- 
tion, 664 
rubber, 664 
silk, 76, 664, 847 
wire, 847 
Line a alba, 90 
nigra, 67 
striata, 67 
Lint, surgeon's, 294 
Lipomata, 795 
Liquor akimini acetici, 597 
ferri chloridi, 730 
ferri sesquichloridi, 762 
Lithopedion, 546, 547, 570 
L3^mphangiectasia, 790 
Lymphatic system, 170 
glands, 170 

hypogastric, 170 
inguinal, 170 
lumbar, 171 
of Guerin, 171 
pelvic, 170 
sacral, 170 
vessels, 171 
Lymphosarcoma, 777 



I M. 

Magnesia mixture, 100 
sulphate, 405, 409, 682 
i Magnesium citrate, 80 
' Malformations, classification and defi- 
j nition of, 181 

I congenital and acquired, 32 
treatment of, 186 
Malignancy, proportion of, in ovarian 

ttimors, 839 
Malignant chorion, 770 
disease, 71 

of colon, 68 
neoplasms, 588 
Malt extracts, 361 
Mammary gland extract, 522, 641 
Marasmus, S3 5, 837 
Martin's method of suturing in lacera- 
tion of perineum, 273 
Massage, 104, 109 
general, 109, 329 
pelvic, 109, 394, 478 
contraindications, iii 
. difficulties of, 1 1 1 

I in anteversion, 457 

' in lateral flexion, 498 

indications for, no 
Masturbation, 202, 288, 298 
Meatus urethras extemus, 153 

construction of, 153 
Membrana granulosa, 151 
Menopause, 178 

chemic changes in blood and tissues, 



179 

duration, 179 
hemorrhasfes during, 



179 



880 



INDEX, 



Menopause, premature, 178 
retarded or delayed, 179 
time of occurrence, 178 
vasomotor disturbances of, 180 
treatment, 180 

Menorrhagia, 24, 114, 176, 350, 351, 

357> 362, 379. 393. 459. S^?. 614, 
618 
Menses, 19 
Menstruation, 175 

after complete removal of ovarian 

stroma, 178 
amount of blood lost, 176 
and ovulation, 175 
disturbance of, 23 

of mental equilibrium in, 176 
duration of, 176 
during pregnancy, 178 
influence of cessation of, upon the 
cervix, 142 
of nerves in, 178 
of ovarian tumors upon, 817 
intervals of, 176 
purpose of, 178 
retained, from atresia, 194 
symptoms of, 176 
synonyms of, 175 
time of occurrence of, 176 
Menthol, 300 
Mercuric oleate, 316 
Mercury, 103 

Mesenteric artery, ligation of, 850 
Metalbumin in cyst contents, 808 
Metastasis chorioepithelioma, 770 
of carcinoma, 726, 756, 793, 837 
papillary variety ovarian tumors, 
850 
Methods for examining tissues, 54 
Methyl blue, 326 
Methylated spirit, 716 
Metritis, 330, 339,343, 455. 47°. 497 
and endometritis, acute, 339 
chronic, 355, 699 

a cause of ante version, 455 
associated with cancer, 356 
course and prognosis, 360 
diagnosis and physical signs, 359 
differential, 359 
from cancer, 359 
from pregnancy, 359 
from rectal disease, 359 
from small fibroids, 359 
divisions of, 356 
etiology, 356 
abortions, 357 
cellulitis, 356 
congestion, 357 
contusions from pessar}^ 357 
inflammation, 356 
lacerations of the cervix, 356 
micro-organisms, 356 
retention of placenta, 356 
subinvolution, 355 



Metritis, chronic, symptoms, 357 
leukorrhea, 358 
menstrual disturbances, 357 
sterility, 358 
synonyms of, 355 
treatment, 360 

abdominal binder, 360 
amputation of the cervix, 362 
counterirritants, 362 
dilatation and curetment, 362 
douches, 360 
drainage of uterus, 365 
Emmet's operation, 362 
ergot, 360, 361 
exercise, 360 
extirpation of uterus, 365 
hip baths, 360 
medicated baths and waters, 

361 
pessary, 360 
preventive, 361 
puncturing and scarifying the 

cervix, 362 
repair of lacerations, 360 
rest, 360 

Schroder's operation, 362 
tampons, 362 
Weir Mitchell's, 365 
diagnosis, 342 

differential, between septicemia 
and sapremia, 342 
infection, how favored, 339 
involving the peritoneal coat, 341 
localized points of infection, 341 
parenchymatous, 288, 330 
pathologic alterations in, 339, 355 
prognosis, 344 
sapremic, 340 
septicemic, 340 
symptoms of sapremia, 340 

of septicemia, 342 
treatment, 344 
hot douches, 344 
Marmorek's antistreptococcic se- 
rum, 345 
prophylactic, 344 
varieties and their source, 340 
Metrorrhagia, 24, 212, 287, 517 
Micro-organisms, 60, 284, 285, 306, 
311, 318, 395_ . r , 

as a cause of inflammation of the 
genito-urinary tract, 284 
Microscope, 53 
Microtome, freezing, 716 
Micturition, frequent, 614 
and painful, 64 
causes of, 23 
Migraine, 176 

Milk a basis for diet in pruritus, 299 
Milliamperemeter, 113 
Miscarriage, 19 

Moles and cysts of the uterus, 684 
tubal, 539 



INDEX. 



881 



Mons veneris, 121 

Monsell's salt, solution of, in glycerin, 

294 
Morcellement , 654 
Morgagni, columns of, 157 
hydatid of, 153, 790, 796 
sinuses of, 157 
Morphin, 98, 100, loi, 325, 381, 393, 
559, 682, 766, 788 
sulphate, 85, 766 
Mortality of ovariotomy, 855 
Motor and sensory paralysis, 21 
Mucilage, 717 
Mucometra, 683 
Mucosa, uterine, alterations of, during 

menstruation, 178 
Miiller, canal of, 183, 796 

duct of, 119, 181, 188, 189, 193 
diverticulum of, 188 
Miiller's fluid, 716 
Multilocular cysts, 806 
Murphy button, 852 
Muscles, 127 

bulbo-cavernosus, 127, 153, 249 

coccygeus, 132, 249 

ischio-coccygeus, 132 

levator ani, 132, 249, 254, 262, 524 

obturator coccygeus, 132 

of Guthrie, 153 

pelvic diaphragm, 132 

perforations of, 133 
pubo-coccygeus, 132 
transversus perinei, 248 
Myomata, uterine, 599, 629, 744, 831 
complications of, 629 
ascites, 629 

disease of the tubes, 630 
inflammation, 629 
ovarian cysts, 630 
pregnancy, 631 
course and prognosis, 634 

cystic degeneration in, 636 
death from chronic peritoni- 
tis, 637 
from disease of kidneys, 

637 
from heart failure, 637 
from inflammation and 

gangrene, 637 
from rupture of cysts, 637 
from shock, 637 
from uremia, 637 
in heart affections, 636 
influence on climacteric, 636 
malignant degeneration, 636 
mortification and gangrene of 

tumor, 636 
mummification, 636 
perforations of neighboring 

organs, 637 
rupture of pedicle, 636 
degeneration of, 603, 624 
adenomyomatous, 603 
56 



Myomata, uterine, degeneration of, 
amyloid, 626 
atrophy, 625 
calcification, 603, 626 
colloid myxomatous, 603, 627 
edema (hematoma), 603, 625 
fibrocystic tumors, 603, 625 
inflammation, suppuration, and 
gangrene, 627 
from compression, 627 
from injury, 627 
from septic infection, 
627 
lymphangiectatic, 603 
malignant, 628 
metabolism, 625 
sarcomatous, 603 
telangiectatic, 603 
diagnosis, 617 

consistence of the tumor an im- 
portant factor, 619 
differential, 620 
from abortion, 620 
from carcinoma, 620 
from displaced ovaries, 620 
from displaced uteri, 620 
from extrauterine pregnancy, 

620 
from floating kidney, 620 
from glandular ovarian cyst, 

620 
from inversion, 620 
from pelvic infiltrations, 620 
from pregnancy, 620 
from sactosalpinx, 620 
from sarcoma, 619 
from subinvolution with en- 
dometritis, 620 
etiolog\^ of, 610 

influence of age ,611 
of heredity, 612 
of irritation, 610 
of menstrual congestion, 612 
of sexual irritation. 612 
influence of, on conception, 631 
on labor, 634 
on pregnancy, 633 
pregnancy on myoma, 632 
microscopic appearance of, 602 
multiplicity of, 600 
necrosis, 603 

pathologic anatomy of, 600 
consistency, 600 
mixed growths, 628 
carcinoma, 628 
enchondroma, 628 
myocarcinoma, 628 
myochondroma, 628 
myosarcoma, 628 
osteoma, 628 
sarcoma, 628 
vascularity, 601 
size of, 609 



882 



INDEX. 



Myomata, uterine, structure of, 602 
symptoms of. 613 

abdominal cramps, 613 
anemia, 615 

apparent inflammation of blad- 
der, 614 
cachexia, 617 
constipation, 614 
dilatation of ureter and pelvis 

of kidney, 617 
displacement of the uterus, 614 
fissure of anus, 614 
frequent micturition, 614 
growths filling up internal os , 6 1 6 
hemorrhage, 613, 614 

associated with peduncu- 
lated polypi, 614, 615 
hemorrhoids, 614 
hydronephrosis, 618 
inability to evacuate urine, 614 
increases of menses, 614 
itching and burning of anus, 

614 
leukorrhea, 615 

marked retention of urine, 614 
metrorrhagia from rupture of 

veins, 614, 615 
pain, 613, 615 

pressure upon nerves and ves- 
sels, 614 
prolapse of rectum, 614 
pulmonary emboli, 637 
renal calculi, 618 
retention of gas, 614 
sacculation of the kidney, 617 
sloughing and gangrene, 614 
sterility, 616 
tympanites, 614 
varicose veins of anus and 

vulva, 614 
vesical tenesmus, 616 
treatment of, 637 
electric, 641 
Apostoli's, 642 
antisepsis, 643 
contraindications, 644 
acute nephritis, 645 
colossal tumors, 645 
fibrocystic tumor, 644 
heart failure, 645 
hysteria, 644 
intestinal catarrh, 644 
malignant degeneration 

of the tumor, 644 
pedunculated submu- 
cous fibroid, 644 
pregnancy, 644 
pus in the adnexa, 644 
very hard tumors, 645 
difficulties of, 643 
electro-puncture, 643 
frequency and duration 
of application, 643 



Myomata, uterine, treatment, electric, 
Apostoli's, galvanism in, 
114 
influence of, 642 

in subserous tumors, 644 
interpolar method, 645 
of negative pole within 

the uterus, 642 
of positive pole within 

the uterus, 642 
polar influence, 645 
prevention of shock, 643 
general, 637 

binder or support, 638 
care in dress, 638 
mineral springs and bath, 
638 
medical, 638 
adrenalin, 641 
carbohydrates, 640 
constringents, 640 
mammary gland extract, 

641 
oxytocics, 639 

promotion of calcareous de- 
generation, 640 
pulmonary edema induced 
by tincture of iodin injec- 
tion, 641 
thyroid extract, 640 
summary of, 674 
surgical, after, 680 

bandaging limbs, 680 
enemata, 681 
hypodermocleisis, 680 
intravenous injections, 680 
rectal feeding, 682 
stomach pump, 681 
suppositories, 681 
in tympanites, 681 
palliative, 645 
radical, 645 
route, abdominal, accidents, 

675 

and results, hemor- 
rhage, 645, 675 

injuries of the hollow 
viscera, 676 
of the intestine, 678 
of the ureter, 677 

ventral hernia follow- 
ing, 664 
castration, 646, 658 

contraindications of, 
660 

difficulties of, 658 

vasomotor symptoms 
resulting from, 660 
enucleation, 661 

advantages of, 662 
hysterectomy, complete, 
or pan-hysterec- 
tomy, 669 



INDEX. 



883 



Myomata, uterine, treatment, surgical, 
abdominal route, 
complete hysterec- 
tomy, advantages 
of intraperitoneal 
treatment of stump , 
664 
Koeberle's operation, 

663 
partial, or supra- vag- 
inal amputation of 
uterus, 663 
ligation of vessels, 660 
myomectomy, 660 
vaginal dilatation and cu- 
retment, 646 
dangers of curet, 648 
dilators, 646 
tents, 646 
incision of the capsule, 
649 
of the cervix, 649 
removal of the growth, 
650 
by enucleation, 652 I 
of interstitial tu- 
mors, 652 1 
of sessile tumors, 
652 ' 
by hysterectomy, 657 ' 
treatment of the I 
wound, 658 j 
by incision of the | 
pedicle, 651 \ 
by ligation of the j 
vessels, 656 , 
by morcellement, 654 I 
by torsion, 650 
varieties of, 602 
cervical, 603, 609 

diagnosis, 609 
extramural, excentric, or sub- 
peritoneal, 603, 607 
ascites with movable, 

608 
encapsulated, 608 
free, 608 
pedicle of, 608 
pedunculated, 608 
sessile, 607 
intramural or submucous, 602 
encapsulated, 603 
nonencapsulated, 603 
pedunculated, 604 
sessile, 604 
mural, interstitial, or centric 
growths, 602 
circumscribe d , general , 

606 
diffuse or gigantic, 606 
hypertrophy of the mu- 
cous membrane, 607 
local, 606 



N. 

Nabothian cysts, 332, 717, 718 
Narcotics, 707, 766 
Nausea and vomiting, 99 
Needle, curved, 763 

Freund's trocar, 739 

Hagedom, 665 

holder, 758 
Needles, 758 
Neoplasms, 323 

malignant, 588 
Nephrectomy for ureteral fistulae, 243 
Nephritis, 593, 598 

acute, 114 
Nerves, coccygeal, 171 

hypogastric plexuses, 171 

inferior hemorrhoidal, 171 

interneal pudic, 171 

of the pelvic organs and structures, 
171, 172 

spinal and sympathetic, 171 

splanchnic, 171 
Nervous disturbances in menstruation, 

176 
Neuralgia, intercostal, 21 

lumbar, iii 

lumbo-abdominal, 11 1 

obscure, jtr-rays in, 117 

ovarian, iii 

visceral, 21 
Neurasthenia, 358 
Nitrite of amyl, 86 
Nitroglycerin, 87 
Nitrous oxid gas, 84 
Noma, 295 
Notes, value of, 19 
Nubility, 174, 175 
Nuck, canal of, 121 

persistence of the, 189 
Nurse, duties of, 99 
Nutrition, disorders of, 21 
Nux vomica, 681 
Nymphae, absence of, 198 

defects of, 198 

hypertrophy of, 198 



Obesity, 22 

Observation, importance of, 18 

Obturator fascia, 131 

vaginal, 225 
Odor, disagreeable, in cancer, 765 
Oil, birch, 326 

carbolized, 765 

castor, 405 

cod-liver, 361 

croton, 106, 362, 380 

sandalwood, 316 

theobromas, 766 
Ointment, belladonna, 302 

and camphorated lanolin, 326 



884 



INDEX. 



Ointment, bismuth, 765 
camphor, 300 
chloral, 300 
chloroform, 300 
condurango and vaselin, 767 
diachylon, 295 
ichthyol, 294, 302 
iodoform, 108, 302 
lead acetate, 300 
mercurial, 316 
mercuric iodid, dilute, 380 
mercury, ammoniated, 295 
opium, 302 
sulphur, 299 
zinc oxid, 310 
Onanism, 301 
Oophorectomy, 658 
Oophoritis, 374 

from gonorrheal infection, 374 
from septic infection, 375 
peri-, 374, 377 
serosa, 376 
Operation, arrangement for, 88 
assistants, 88 
closure of wound, 95 
clothing of patient, 89 
incision, 90 

peritoneum, toilet of, 91 
position of operator and assistants, 

88 _ 
precautions during, 79 
preliminary details, 88 
examination and preparation of 

patient for, 79 
preparation, special, 81 
room and environment, 79 
Operations, abdominal section, 8^, 90, 
406 
Alexander's, modifications of, 
by Buret, 485 
by Edebohls, 485 
by Franklin Martin, 485 
by Goldspohn, 486 
by Newman, 485 
accidents and results of, 243 

calculi and calcareous concre- 
tions, 245 
inclusion of the ureter, 244 
peritonitis, 245 
primary hemorrhage, 243 
secondary hemorrhage, 243 
bladder, for carcinoma of, 598 
cureting for inflammation, 327 
extirpation of, for cancer, 598 
tumors, removal of, through the 
urethra, 593 
abdominal incision for, 

594 
vaginal incision for, 593 
cervix, amputation of, 218, 446 
Baker's, 724 
flap, double, 219 
single, 219, 339 



Operations, cervix, amputation of, 

Hegar's, 724 
Schroder's, 724 
vaginal, for cancer of uterus, 

722 
Van de Warker's, 724 
with galvanocautery loop, 723, 

incision for contracted os, 337 
laceration of, trachelorrhaphy 
(Emmet), 216, 338 
fistula, entero- vaginal, 247 
recto- vaginal, 245 
uretero-vaginal - uretero-cervical, 

240 
vesico-utero- vaginal, 238 
vesico-uterine , 236 

hysterocleisis, 238 
vesico-vaginal, 225 
colpocleisis, 233 
flap -formation, 231 
transplantation, 230 
Trendelenburg's operation, 
230 
for neoplasms, removal of growth 
by incision of the pedicle, 

651 
by morcellement, 654 
by torsion, 650 
ovary and tube, l3y abdominal inci- 
sion, castration, 645, 658 
for fibroid growths of 

uterus, 658 
for oophoritis, 381 
for prolapse of ovary, 516 
by ovariotomy, 839 

incomplete, for ovarian tu- 
mors, 849 
removal of, for inflammatory 
diseases, 407 
with uterus by vaginal inci- 
sion, 412 
shortening of infundibulopelvic 
ligament for fixation of, 516 
pelvic floor, for lacerations of, by 
denudation, Bischoff's, 

273 
Cleveland's, 270 
Dudley's, A. P., 271 
Emmet's, 266, 269 

Noble's modification of, 
268 
Freund's, 265 
Hegar's, 260 

Garrigues' modification 
of, 260, 449 
Heppner's, 264 
Hildebrandt's, 263 
intermediate operation, 

255 
Lauenstein's suture, 263 
Martin's, A., 265, 273 
Outerbridge's, 269 



INDEX. 



885 



Operations, pelvic floor, for lacerations 
of, by denudation, prim- 
ary, 253 
secondary, 256 
Simon-Hegar, 258 
by flap ,231 
Andrews', 274 
Duke's, 279 
Fritsch's, 278 
Harris', 274 
Noble, 278 
Ristine, 277 
Sanger's, 276, 277 
Simpson's, 278 
Tait's, 275 
for pregnancy, extrauterine, 
elytrotomy, 559 
incision, abdominal, after 
rupture, 560 
before rupture, 560 
vaginal, 560 
for prolapsus, Baldy's, 451 
colporrhaphy, anterior, 449 

posterior, 449 
Dudley's, E. C, 452 
Emmet's, 449 
Freund's, 450 
Garrigues-Hegar, 449 
Gilliam-Ferguson's, 450 
Hegar's, 449 
Hirst, 511 
Noble's, 452 
Ries, 450 
plastic, 102 
sacral, 590, 744 
Krasice's, 744 

modifications of, by Borelius, 
748 
by Hegar, 747 
by Heinecke, 748 
by Herzfeld, 746 
by Hochenegg, 744 
by Kocher, 748 
by Levy, 748 
by Rydygier, 748 
by Schede, 747 
bv Schlange, 748 
by Wolffler, 748 
by Zuckerkandl, 748 
to construct a vagina, 191 
upon the uterus, for displacements, 
anteflexion, abdominal, 

459 
vaginal, Dudle^^'s, 467 
Nourse's, 467 

splitting posterior lip, 466 
ante version, 454 

Sims', 457 
inversion of the uterus, ab- 
dominal incision, Thomas, 

vaginal incision, Kiister's, 
510 



Operations upon the uterus, for dis- 
placements, retrodis- 
placements, abdomin- 
al, Alexander's short- 
ening of round liga- 
ments, 450, 483 
modified by Cassati, 485 
Doleris, 485 
Duret, 485 
Edebohls, 485 
Goldspohn, 486 
Martin, F., 485 
Newman, 485 
intraperitoneal shortening 
of round ligaments, 
Dudley's (desmopyc- 
nosis) , 489 
Mann's, 488 
Wylie's, 488 
ventrofixation and ventro- 
suspension, 491 
vaginal, Diihrssen's, 495 
Freund's, 496 
Gottschalk's, 496 
Mackenrodt's, 495 
Pryor's, 496 
Schiicking's, 495 
Vineberg's, 496 
Wertheim's, 496 
for neoplasms, abdominal, 739 
castrations, 658 
enucleations, 661 
hysterectomy, modified by 
Bardenheuer, 739 
by Bishop, 673 
by Clark, 740 
by Crede, 739 
by Eastman, 739 
by Gubaroft", 739 
by Kelly, 740 
by Kuhn, 739 
by Mackenrodt, 742 
by Martin, A., 739 
by Polk, 741 
by Ries, 740 
by Rumpf. 740 
by Schroder, 742 
by Simpson, 739 
by Veit, 739 
by Werder, 740 
supravaginal or partial hys- 
terectomy, 663 
modified by Baer, 665 
by Bishop, 668 
by Gow, 664 
by Le Bee, 665 
bv Marcy, H. O., 664 
by Pry or- Kelly, 666 
by Zweifel, 664 
vaginal hysterectomy, 81, 

657. 729 
modified by Billroth, 730, 

731 



886 



INDEX. 



Operations for neoplasms, abdominal, 
vaginal hysterec- 
tomy, modified by 
Bottini, 731 
by Bovee, 729, 733 
by Byrne, 734 
by Calderini, 731 
by Clark, 733 
by Corradi, 731 
byCzerny, 729, 730, 732, 

734 
by Downes, 735 
by Doyen, 731 ^ 
by Diihrssen, 7*32 
by Eastman, 736 
by Franck, 734 
by Fritsch, 731 
by Frommel, 734 
by Kaltenbach, 732 
by Kelly, 731, 733 
by Landau, 731 
by Langenbeck, 734 
by Leopold, 730 
by Liebmann, 732 
by Mackenrodt, 731, 

733. 734 
by Mikulicz, 730 
by Miiller, P., 731 
by Newman, 735 
by Olshausen, 730, 731, 

732 
by Pawlik, 733 
by Pean, 735 
by Richelot, 735 
by Schatz, 731 
by Schauta, 731 
by Schroder, 731, 732 
by Schuchardt, 733 
by Tauffer, 730 
by von Teuffel, 732 
by Tuffier, 735 
by Veit, 732 
by Wecchi, 731 
by Winckel, 732 
by Winter, 734 
curetment, 646 
incision of capsule, 649 
of cervix, 649 
ligation of vessels, 656 
removal of growth, 650 
by enucleation, 652 
vulvar, Bartholinitis, 297 
epispadias, 205 
excision of elephantiasis, 580 
of urethral caruncle, 576 
of vulvar vegetations, 578 
extirpation of malignant disease 
of, 585 
Operator and assistants, 78 

positions of, 88 
Opium, 299, 325, 381, 393, 404, 766 
with belladonna, 325 
with stramonium, 325 



Organ of Rosenmiiller, 148, 794, 796, 

Organs, interrogation of other, 19 
pelvic, abnormal communications 
of, 206 
Os, external, 141 
internal, 142 
tincae, 141 
Osteoma, 628 
Ovaralgia, 115 
Ovarial tubes of Pfliiger, 150 
Ovarian abscess, 374 
apoplexy, 152, 517 
growths a cause of ante version, 455 
hematoma, 152 
prolapse, 515 

tumor, benign, complicated by ma- 
lignant disease of uterus, 699 
tumors, 322, 630, 744, 796 
adhesions of, 836 
characteristics of, 796 
classification of, 796 
dermoid, 810, 820, 821 

contents of, 810 
large, 798 

glandular cystomata, 801 
proliferous, 801 
proligerous, 801 
size of, 801 
structure of, 805 
areolar, 806 
multilocular, 797, 806 
cyst contents, 797, 
808 
color of, 808 
consistence of, 808 
specific gravity, 808 
unilocular, 796, 806 
glandular proliferous, 798, 
801, 835 
pedicle of, 802 
papillary proliferous, 809 
parovarian, 811, 836, 837 
contents of, 812 
dermoid, 798, 812 
how distinguished from 

ovarian, 812 
hyaline, 798 
papillary, 798 
proliferating, 812 
specific gravity, 812 
weight of, 812 
small, 796, 798 

cysts of corpus luteum, 800 
residual, 798 

hydatid of Morgagni, 
798 
simple or follicular (hy- 
drops folliculorum) , 

799 
etiology of, 800 
specific gravity of con- 
tents, 799 



INDEX, 



887 



Ovarian tumor, classification, small, 
cysts, tubo-ovarian, 
800 
adhesions of, 834 
complication of, 817 

inflammation and suppuration, 
820 
symptoms of, 820 
pregnancy, 822 
rupture, 821, 837, 850 
torsion of pedicle, 817 

differential diagnosis of 
acute, from gall- 
stone colic, 835 
from ileus, 835 
from perforation of in- 
testine, 835 
from perforation of 

stomach, 835 
from peritonitis, 835 
from renal colic, 835 
from ruptured ectopic 

gestation, 835 
from ruptured ovarian 
cyst, 835 
symptoms, 820 
degenerative changes in the walls, 
824 
atheromatous, 824 
calcification, 824 
fatty degenerations, 824 
infarctions, 824 
diagnosis, 824 
differential : 

from ascites, 826 
from desmoid tumor of ab- 
dominal walls, 825 
from distended bladder, 826 
from fecal accumulation, 826 
from inflammatory growths 

of tubes, 831 
from large abdominal tu- 
mors, 831 
from localized peritoneal ef- 
fusion, 829 
from obesity, 825 
from other abnormal col- 
lections, 834 
from tumors of broad liga- 
ment, 831 
from tympanites, 825 
from uterine fibroids, 831 
from ventral hernia, 825 
from extrauterine gestation, 832 
from hematometra, 834 
from hydramnios, 832 
from hydrometra, 834 
from physometra, 834 
from pregnancy, 831 
from retroperitoneal growths, 

834 
from tumors of abdominal vis- 
cera, 831 



Ovarian tumor, diagnosis, from uterine 
myomata, 833 
questions to be considered in, 
824 
exploratory incision, 838 
puncture, 837 

danger and disadvan- 
tage of, 838 
etiology, 814 
natural progress, 815 
pedicle of, 802 
prognosis, 853 
solid, 812 

endothelioma, 814 
fibromyoma, 812 
weight of, 812 
gyroma, 813 
symptoms, 816 
treatment, 838 
electrolysis, 838 
extirpation, 839 
ovariotomy, 839 

causes of death after, 
854 
hemorrhage, 854 
ileus, 854 
peritonitis, 854 
shock, 854 
tetanus, 854 
contraindications for, 840 
bronchial catarrh, 840 
gastro-intestinal catarrh, 

840 
intercurrent fevers, 840 
irrecoverable, disease of 
heart, 840 
of kidneys, 840 
of liver, 840 
of lungs, 840 
marasmus, 840 
nephritis, 840 
pulmonary tuberculosis, 

840 
valvular disease of 

heart, 840 
visceral injuries during, 

851, 852 
weakness from loss of 
blood, 840 
general considerations, 841 
closure of wound, 843 
drainage, 843 
dressing, 843 
incision of abdominal 

wall, 842 
instruments, 841 
management of pedicle, 

846 _ 
operation, 842 
postoperative treat- 

ment, 849 
puncture and evacua- 
tion of cyst, 838 



888 



INDEX. 



Ovarian tumors, treatment, extirpa- 
tion, ovariotomy, gen- 
eral considerations, re- 
moval of cyst and 
management of adhe- 
sions, 843 
toilet of peritoneum, 848 
incomplete operation, 849 
indications for, 839 

compression of lungs, 840 
suppuration of cyst, 820 
symptoms of hemorrhage, 
840 
of ileus, 840 
of rupture of cyst, 840, 

850 
of uremia, 840 
torsion of pedicle, 835 
intestinal complications, 854 

volvulus, 854 
mortality of, 855 
prognosis, 853 % 

Ovaries, absent or rudimentary, 188 
accessory or constricted, 189 
anatomy of, 147 
axes of, 148 
color of, 149 

connection with infundibulopelvic 
ligament, 148 
with uterus and tube, 148 
displacement of, 189 
electricity in chronic inflammation 

of, 114 
Graafian follicles of , 151 
inflammation of, 514 
malformations of, 188 
situation of, 148 
size of, 149 
stroma of, 151 
supernumerary, 188 
tubes of Pfliiger, 150 
Ovariotomy, 839 

visceral injuries in, 851 
to bladder, 853 
to intestine ,851 
to rectum, 852 
to ureter, 852 
Ovaritis, 307, 352, 374 
Ovary, abscess of, 374 

apoplexy of, 152, 374, 375, 517 
cancer of, 699 
carcinoma of, 814 

complications of, 817 
adhesions, 817 
ascites, 817 
distention of ureter and pelvis 

of kidney, 817 
edema, 817 
etiology of, 814 

acquired disposition, 815 
age, 815 
heredity, 815 
inflammation, 815 



Ovary, carcinoma of, etiology of, trau- 
ma, 815 
natural progress of, 815 
symptoms of, 816 
cirrhosis of, 377 
function of, 377 
hematoma of, 374 
inflammation of, 374 
acute, 374 
chronic, 374 
diagnosis of, 378 
gonorrheal, 374 
septic, 374 
symptoms, 378 

pain only constant, 378 
treatment, 379 

care in the use of drugs, 380 
ice-bag, 379 
removal of ovary, 382 
rest, 383 
ligament of, 148 
prolapse of, 515 
sarcoma of, 792 
Ovula Nabothi, 145, 332, 335 
Ovulation and menstruation, 175 

without menstruation, 178 
Oxygen, mixture of chloroform and, 86 
Oxytocics, 639 



P. 

Pain, 24 

in myomata, 613, 615 
seats of, 24 
accessory, 25 

anal or perineal, 25 
pelvic, 26 
vaginal, 26 
principal, 24, 25 
hypogastric, 25 
iliac, 25 
lateral, 25 
•lumbar, 25 
sympathetic, 21 
Panhysterectomy, 669 
Papilloma of the ovary, 571 

superficial, 809 
Papillomata of tube, 791 
of vagina, 588 
of vulva, 578 
superficial, 836 
Paracentesis abdominis, 70 
Paraffin, melted, 297 
Paralbumin, in cyst contents, 808 
Paralysis, motor and sensory, 21 
Parametritis, 288, 384 

chronica atrophicans circumscrip- 
tum et diffusum, 386 
posterior, 386 
Parametrium, 162 
Parauterine pouch, 161 
Paris, plaster-of-, injections of, 163 
Parovarian phleboliths, 795 



INDEX. 



889 



Parovarian tumors, diagnosis of, 836 
Parovarium, 133, 153, 

description of, 153 
Pars intermedia, 129 
Parturition, 174, 209 
Patient, comfort of, 98 

examination and preparation of, 79 
preparation of, for ovariotomy, 841 
Peat baths, hot, 498 
Pedicle, 802 

management, 846 
PedicuH, 32, 298, 299 , 

Pelvic diaphragm, 132 
action of, 133 
floor, lacerations of, 248 
causes of, 249 
complete, 250 
degree or extent of, 250 
incomplete, 250 
results of, 251 
treatment of, 252 
perforations, 133 
inflammations, 384, 821, 853 
organs, study of, as a whole, 173 
deviations of, 421 
Pelvis, plane of, 173 
Pencils, copper sulphate, 354 
silver nitrate , 354 
zinc chlorid, 354, 761 
sulphate, 354 
Penis captivus, 302 
Peptonized milk, 100 
Perforation of intestines, 835 
of stomach, 835 
of uterus, 211 
Perimetritis, 394 
Perineal muscles, 132 

bulbocavernosus ,127 
erector clitoridis, 127 
levator ani, 127, 132, 249, 254, 

268, 423 
sphincter ani, 127 
transverse perinei, 127, 248 
operation for removal of uterus, 751 
Perineum, laceration of, 248 
causes of, 249 
degree or extent of, 250 
results of, 251 
treatment of, 252 

intermediate operation, 255 
primary operation, 253 
advantages, 254 
contraindications, 255 
secondary operation. See Lac- 
eration of the pelvic floor. 
muscles of, 127 
Perioophoritis, 374, 377, 394 
Perisalpingitis, 394 
Peritoneum, pelvic, 159 
depression of, 161 
division of pelvic cavity by, 160 
reflections of, 160 
toilet of, 91, 848 



Peritonitis, pelvic, 384, 394, 819, 821, 
822, 829, 835 
diagnosis, 402 

differential, from cellulitis, 402 
from pelvic hematocele, 402 
etiology, 394 

complications during parturi- 
tion, 395 
favored by appendicitis, 395 
following operation for urinary 

fistula, 245 
gonorrheal salpingitis, 403 
idiopathic, 395 
new pelvic growths, 397 
pelvic hematocele, 395 
sepsis, 397 
tubal disease, 395 
twisting of pedicle of ovarian 
cyst, 835 
pathologic anatomy, 398 

intraperitoneal abscess, 399 
suppurative peritonitis, 65, 
399. 409 
prognosis, 402 
symptoms, 400 
treatment, 403 
medical, 404 
preventive, 404 
surgical, 406 

incision, abdominal, 406 

closure of the wound, 
410 
sutures in, 410 
difficulty in adhesions, 

406 
drainage, 409 

postural, 409 
in collapse, 405 
intestinal injections of 

cathartics, 409 
irrigation, 409 
protection of general 

peritoneum, 409 
steps of operation, 406 
vaginal, 406 
section, vaginal, and uterine 
castration, 412 
tubercular, 829 
Periuterine inflammation, 115, 384 

phlegmon, 384 
Perivaginitis, 288 
Pessaries, 444 
use of, 444 

contraindications to, 481 
Pessary, 444 
bulb, 444 
cup, 445 
disc, 444 
Gariel, 225 

Grailey Hewitt, 444, 464 
Hodge, 478, 480 
Munde, 444, 478 
ring, 444 



890 



INDEX. 



Pessary, Schultze, 478, 480, 481 
figure-of-8, 480 
sledge, 480 

Smith-Hodge, 444 

Thomas, 444, 464, 478 

Zwank, 444 
Phenols, 765 
Phleboliths, 795 
Phlegmasia, 618 
Phlegmon, periuterine, 384 
Physical signs, 20 

senses employed in determining, 
28 
Physiology of genital organs, 174 
Physometra, 683, 834 
Picrocarmin, 717 
Picrotoxin, 180 
Pin-worms, 299 

Placenta prcevia in myoma, 633 
Placental polypus, 685 
Plaster, mustard, 522 
Platinum wire electrode, 113 
Pledget, 760, 761 

cotton, 760, 761 

gauze, 758 
Plicae palmatse, 145 
Plug, glass, 191 
Pneumonia, 72 
Podophyllin, 102 

Poison, diphtheritic or venereal, 313 
Polypi, mucous, of the uterus, 684 

uterine, 684 
Polypus, fibroid, 604 

intermittent, 618 
Positions for examination, 29 
dorsal, 29 
erect, 32 
genupectoral, 31 
lateral, 29 
lithotomy, 751 

semi-prone or Sims', 30, 736, 744 
Trendelenburg, 31, 594, 738, 851 
Potassium bromid, 299 

chlorate, 361 

citrate, 393 

iodid, 102, 361 

permanganate, 105, 765 

salts, 640 
Pouch of Douglas, 161, 163 

parauterine, 161 

pubo- vesical, 161 

subperitoneal, 162 

utero-rectal, 160 

vesico-abdominal, 161 

vesico-uterine, 160, 161 
Poupart's ligament, 130, 163, 170 
Powders, alum and sugar, 294 

aristol and desiccated alum, 294 

bismuth subnitrate, 294 
and chalk, 310 

boric acid and tannin, 759 

charcoal and iodoform, 764 

iodoform, 108, 294 



Powders, iodoform and tannin, 294, 
310 
lycopodium, 294 
pepsin and salicylic acid, 763 
seidlitz, 102, 681 
starch, 294 
talcum, 294 
Pregnancy, 114, 116, 620, 625, 632, 
^U^ 713. 822, 831 
abdominal, 536 
complicating carcinoma, 712, 713 

ovarian tumors, 822 
extrauterine, 533 
causes of, 533 
course and progress of, 537 
varieties of, 535 
in bicornate uterus, 555 
ovarian, 535 
spurious, 555 

tubal, 535, 536. See Ectopic ges- 
tation. 
tubo-ovarian, 535 
tubo-uterine , or interstitial, 536 
with retroflexed uterus, 318 
Probe, Sims', 40 

uterine, 40 
Procidentia, 252, 428 
Prolapse of ovary, 515 
Prolapsus, or descent, 428 
bandages in, 443 
classification of, 428 
pseudo-prolapsus, 428 
utero- vaginal, 428 
vagino-uterine, 428 
complete or incomplete, 428 
complicating ovarian tumor, 816 
congenital, 188 
degrees of, 428 
first, 428 
second, 428 
third, 428 
diagnosis of, 435 

differential, from cyst in anterior 
wall of vagina, 438 
from cystocele, 435 
from elongated cervix, 436 
from enterocele, 439 
from fibroid polypus, 438 
from inversion of uterus asso- 
ciated with inversion of 
vagina, 438 
from rectocele, 435 
dress and hygiene as a cause, 430 
etiology of, 429 

abdominal growths in, 431 
symptoms of, 431 
cystocele, 432 
leukorrhea, 434 
rectocele, 432 
treatment, 442 
hygienic, 442 
mechanical, 442 
operative, 442 



INDEX. 



891 



Prolapsus, varieties of, 428 
Proliferous cysts, 809 

papillary, 798 
Proligerous cysts, 801 
Pruritus vulvas, 298 
idiopathic, 298 
prognosis of, 298 
specific cause of, 298 
symptoms, 298 
treatment, 299 

guaiacol in, 300 
with cancer of the uterus, 708 
Pryor's operation for displaced uterus, 

496 
Psoriasis vulvae, 584 
Puberty, 174 

changes associated with, 174, 175 
definition of, 174 
influence upon discharge, 27 
precocious, 174 
retarded, or delayed, 175 
time of occurrence of, 174 
Pubovesical ligaments, 154 

pouch, 161 
Pudendal sac, 130 
Pudendum, 121 

Puncture, exploratory, 70, 637, 837 
of cysts preliminary to ovariotom}^ 
841 
Purgation, 102, 766 

before ovariotom}^ 848 
Pyelonephritis, 319 
Pyelonephrosis, 72 
Pyocolpos, 197 
Pyometra, 683, 779 
Pyosalpinx, 307, 399, 400, 402, 630, 

.709. 831 
Pyrosis, 23 

Quassia, 299 
Quicksilver, 758 

Quinin, 100, 103, 336, 345, 361, 405, 
681 



R. 

Reconstructives, 103 
Rectal douche, 105 

feeding, 100, 682 

touch, 38 
Rectocele, 32, 252, 266, 272, 432 
Rectovaginal fistula, 221, 245 
Rectum, ampulla of, 156 

anal orifice of, 157 

anatomy of, 156 

crypts of, 157 

injury to, during operation, 852 
in vaginal hysterectomy, 737 

lymphatics of, 171 

mucous membrane of, 157 
Reflexes, rectal, 22 

vesical, 23 



Remedies, specific, 103 
Renal calculus, 433 
colic, 835 
dilatation, 617 
Residual cysts, 798 
Rest and exercise, 104 

treatment, 365 
Retractors, wooden, 759 
Retroflexed gravid uterus, 555 
Retroflexion of the uterus, 426, 469. 
See Retroversion. 
diagnosis of, 471 

dift'erential, from adherent ova- 
rian growths, 471 
from fibroid growths, 471 
from pelvic inflammatory 
exudation, 471 
etiology of, 470 
examination in, bimanual, 472 

vaginal and rectal, 472 
immobile, 469 
indift'erent, 469 
mobile, 469 
pathologic, 469 
symptoms of, 470 
Retroperitoneal growths, 834 
Retroposition of the uterus, 453 
Retroversion, 457 

an early stage of prolapsus, 458 
and retroflexion, treatment of, 473 
adhesions, 487 
desmopycnosis, 489 
in adherent uterus, 476 
in non-adherent uterus, 478 
intraperitoneal methods for, 

487 
methods for replacing the 

organ, 474 
operative, 482 

Alexander's operation, 483 
advantages, 486 
disadvantages of, 486 
Schultze's method, 477 
vaginal operations in, 495 
ventrofixation, 491 
advantages of, 493 
disadvantages of, 493 
massage, 477 
pessary in, 478 
use of sound in, 475 
ventrosuspension, 491 
diagnosis of, 459 
etiology of, 458 
symptoms of, 459 
constipation, 459 
cystitis, 459 
fissure of anus, 459 
hemorrhoids, 459 
inflammatory complications, 459 
interference with rectal circula- 
tion, 459 
menorrhagia, 459 
Rheostat, 113 



892 



INDEX. 



Rima pudendum, 121 
Ront genie rays, 116 
Room and environment , 7 9 

operating, 79 

preparation of, 79 
Rosenmiiller, organ of, 148, 794, 796, 

798 
Round ligament, extraperitoneal 

method of shortening, 483 
Rubber gloves, 79 

skirt, 765 
Rubin and orange, 717 
Rupture of cystic tumors, 821, 840 

ectopic gestation, 392 

uterus, 211, 823 
treatment of, 211 



S. 

Sacral resection, 744 
Saline, 379 

cathartic in suppurative peritonitis, 
409 
Salol, 82, 765 

and aristol, 765 
Salpingitis, 365, 366, 497 

avenues of infection, 366 

cysto-adenosa, 369 

diagnosis of, 372 

hematosalpinx, 367, 790 

hydrops tubae profiuens, 369, 801 

hydrosalpinx, or sactosalpinx, 367, 
790 

nodosa mistaken for myoma, 789 

pathological changes in, 366 

peri-, 373 

prognosis, 374 

pyosalpinx, 367 

symptoms, 371 

treatment, see Sec. 390 
Salts, alkaline, 326 

ammonia, 640 

benzoin, 224 

bromid, 326, 640 

Epsom, 80, 102 

iron, 519, 522, 579 

manganese, 104 

potash, 361, 640 

Rochelle, 80, 102 

zinc, 761 
Sand or peat baths, hot, 498 
Sandal-wood oil, 316 
Sanger's sutures, 276 
Santonin for pin worms, 299 
Sapremia, 342 

diagnosis of, 342 

symptoms of, 342 

treatment of, 344 
Saprophytes, 286, 340, 780 
Sarcoma, 628, 686, 773, 783, 813, 836 

diagnosis, 783 

differential, from carcinoma of 
uterine body, 786 



Sarcoma, diagnosis, differential, from 
chorioepithelioma, 787 
from chronic metritis, 784 
from fungous endometritis, 784 
from interstitial endometritis, 

785 
from mucous polypi, 784 
from senile endometritis, 783 
from subinvolution, 785 
from submucous myoma, 783 
from tuberculosis of endome- 
trium, 786 
microscopic examination in, ne- 
cessity of, 784 
duration of, 782 
etiology of, 778 
pathology of, 773 
recurrence, 786 
symptoms, 779 
cachexia, 781 
discharge, 779, 780 
emaciation, 781 
hemorrhage, 779 

increase of tumor after meno- 
pause, 781 
pain, 780 
treatment, 787 
operative, 788 

contraindications for, 787 
varieties of, 773 
of body, 773 
of cervix, 773 
of uterine wall, 773 
Scalpels, 91 

Schroder's operation, 353 
Schucking's operation, 495 
Scissors, 768 
curved, 227 
Kuchenmeister's, 52 
Sclerosis, cervical, 334 
Seats of pain, 25 

Secretion from Fallopian tubes and 
uterine cavity, 26 
from vagina and vulva, 26 
Section, abdominal, 83 

antero-posterior vertical incision, 

419 
control of hemorrhage, 417 
dressings, 415 
pus sacs in, 417 
reason for preferring, 412 
steps of operation, 413 
Segregator, 66 

Seidlitz powder for nausea, 681 
Senna, 299 
Sepsis, 72, 709, 783 
Septicemia, 343, 397, 560, 608, 679 
symptoms, 343 
treatment, 344 
Serum, antistreptococcic, 345 
Sessile fibroid, 604 
Shock, 72, 10 1, 643, 679, 854 
Sight, use of, in diagnosis, 28 



INDEX. 



893 



Signs, phj^sical, 28 

senses in study of, 28 
Silk, carbolized, 664 
iodoform, 76 

ligatures and sutures, 76, 664 
Silkvv^orm-gut , 77, 226, 253, 257 
Silver nitrate, mitigated stick of, 300 
solid stick of, 106, 300, 338 
salts, 597 
Simple cysts, 799 
Simpson's operation in laceration of 

perineum, 278 
Sinistroflexion, 496 
Sinuses of Morgagni, 157 
Sinusoidal current, 115 
Sitz-bath, 105, 764 

hot, 293, 309, 498 
Skene's ducts, 125 

follicles, 311 
Sloughing fibroids, 83 
Smell, how used, 28 
Soap, green, 75 

potash, 295 
Sodii bicarb., 761 
Solutions, acetic alum, 764 

acid, boric, 98, 105, 293, 309, 326, 
327.. 328, 595 
carbolic, 79, 81, 98, 293, 299, 302, 

310, 580, 664, 760 
chromic, 353 
hydrocyanic, 299 
nitric, dilute, 225 
salicylic (alcoholic), 763 
sublimate, 79 
alum sulphate, 310 
aluminium acetate, 523 
antipyrin, 92 
antiseptic, 79 
atropin. 98 

bichlorid. See Suhlimate. 
bismuth in glycerin, 310 
boroglycerid (50 per cent.), 354, 362 
bromin (alcoholic), 730 
chloral, 302 

chloroform in glycerin, 299 
cocain, 87, 98, 299, 316 
corrosive sublimate. See Suhlimate. 
creolin, 105, 310 
ergotin, 98 
ferripyrin, 92 
formaldeh^'d, 580, 760 
formalin, 82, 196, 215, 220, 347, 353, 

364, 464, 730 
hydrastis, fl. ext., 317 
ichthyol, 109, 327 

in glvcerin, 109, 215, 338, 354, 362 
iodin. tinct. co., 294 
iodoform in ether, d>2, 216, 338, 464, 

716 
iron, 762 

perchlorid, 641 
persulphate, 579, 760 
Labarraque's, 82 



Solutions, lead acetate, 301, 310 
liquor alumini acetici, 597 
lysol, 310 

magnesium sulphate, 409 
mercurol, 294, 317, 353 
Monsell's salt in glycerin, 294 
morphin, 98, 10 1 
normal salt, 215 
potassium bichromate, 77, 716 
bromid, 299 

permanganate, 78, 105, 310, 353 
pyoktanin, 326, 763 
pyroligneous acid, 214 
saline, 229, 732, 849 
silver nitrate, 108, 214, 294, 297, 

299. 31.0. 316, 327, 328. 763 
sodium bicarbonate, 216, 353, 761 
chlorid (normal), 93, 327, 344, 

353' 409, 563, 849 
hyposulphite, 294 
strychnin, 103 

sublimate, 74, 80, 81, 98, 196, 215, 
216, 220, 282, 293, 310, 316, 327, 
364, 578 
alcoholic, 729 
thymol, d,2, 105, 765 
zinc chlorid, 108, 214, 760 
sulphate, 310, 317, 2>2,7 
Sound, 39, 40 
dangers of, 476 
perforations of uterus by, 42 
precautions in use of, 42 
replacement of uterus by, 475 
Simpson's, 40 
Specula, urethral, 65, 593 

uterine, varieties of, Edebohls', 47 
Goodell's, 44 
Higbee's, 44 
Nelson's, 43 
Nott's, 43 

Sims' self-retaining, 46 
tubular, 42 
uni valvular or duck-bill, 45 

method of use of, 45 
valvular, 43 
Talley's, 44 
Sphincter ani, 127 
extemus, 128 
intemus, 159 
laceration through, 248 
tub«, 147 
vaginas, 129 
vesicae, 154 
Spigelia, 299 
Spina bifida, 188 
Spinal anesthesia, 87 
Sponge packs, 565 
Sponges, 74, 567, 842 
definite number of, 88 
gauze pads for, 74 
Spray, 79 

Springs, Elster, 638 
Franzenbad, 638 



894 



INDEX. 



Springs, Halle, 638 

Kreuznach, 638 

Tolz, 638 
Staphylococcus albus, 60, 285 

pyogenes aureus, 60, 285, 305, 318, 

r. .395 

Static machine, 116 
Steel electrode, 113 
Sterility, 23, 358, 386, 393, 402, 458, 
616, 631 

a cause of ectopic gestation, 534 
Sterilization methods, 73 
boiling, 74 
fractional, 73 
heat, 73 
steam, 73 

of dressings, 77 

of instruments, 73 

of ligatures and sutures, 76 
Sterilizer, Arnold's, 73 
Stethoscope, 69 
Stitch, crown, 268 
Stomach-pump, 681 
Stomach-tube, 100 
Stramonium, 325 
Streptococcus pyogenes, 62, 285, 305, 

3.06, 395 
Stricture, rectal, 223 
Strontii salicylate, 325 
Strychnin, 71, 98, loi, 103, 303, S3^i 

345; 361, 559. 842, 848 
Styptics, 108, 722 
Subinvolution of uterus, 355, 620 
Subperitoneal growths of uterus, 607 
Sulphate of zinc, 108, 522 

crayons, 108 
Sulphonal, 299 
Suppositories,' 766 

cocain hydrochlorate, 325 
in cacoa-butter, 316 

ice, loi, 533, 681 

lead acetate, 310 

quinin, 345 

santonin, 299 

tannin and iodoform, 310 

zinc oxid, 310 
Suture, ligature and, material, 76 
Sutures, 95 

catgut, 226, 674, 729 

cobbler, 664 

figure-of-8, 270, 410 

Haughey, 96, loi 

interrupted, 95 

Lembert, 665 

mattress, 763 

perineal, 253, 260 

quill or bar, 259 

rectal, 260 

removal of, 10 1, 102, 682 

silk, 226 

silkworm-gut, 226 

silver wire, 226, 450, 742 

Stolz's purse-string, 448, 500 



Sutures, vaginal, 260, 263 
Symptoms, general, 20 
anemia, 21 
chlorosis, 21 

disorders of nutrition, 21 
gastric, 20 
hemorrhage, 24 
pains, sympathetic, 21 
paralysis, motor and sensory, 21 
visceral, 21 
genital, 23 
local, 22 
objective, 28 
subjective, 20 
Syncope and death after removal of 

large tumors, 851 
Syncytio malignum, 770 
Syringe, bulb, 215 
fountain, 215 

hypodermic, methods of infection, 
98 
precautions in use of, 98 



T. 

Table, Chadwick's, 28 

suitable, 28 
Tait's operation in laceration of peri- 
neum, 275 
Tamponade in cancer, 764 
Tampons, absorbent cotton, 108, 214, 
338 

borated, 299, 764 

boroglycerid in glycerin, 354, 362 

carbolic acid, 362 

carbolized, 299 ' 

cotton and gauze, 362 

gauze, 108 

glycerin, 338, 498 

ichthyol in glycerin, 338, 362 
in lanolin, 310, 338, 362 

iodoform gauze, 443, 456, 764, 789 

iron chlorid, 762 

lamb's wool, 108 

saturated with fat and oily mix- 
tures, 765 

sublimated, 299 

sulphurous acid and boroglycerid, 
300 
Tannin, 109, 663, 764 

glycerite of, 109 
Tapping, or paracentesis abdominis, 

70, 72 
Temperature, elevation of, 735, 854 
Tenaculum, 47 
Tents for dilatation, 48 

laminaria, 48, 456, 646, 674, 716 

preparation of, 48 

sponge, 48 

sterilization of, 464 

tupelo, 48, 731 

use of, 83 



INDEX. 



895 



Teratoma, 8ii, 836 
Testicular fluid, 10 1 
Tetanus after abdominal hysterec- 
tomy, 742 

after ovariotomy, 680 
Therapeutics, 72 

classification of, 72 

extension of, 72 

local, 105 
Thermo-cautery, 224, 301, 302, 317, 

578, 585. 731. 759, 761, 763 
Paquelm, 338, 759, 762 
Thirst, 99 
Thrombi from exploratory puncture, 

637 
Thrombus, vulvar, 523 

vulvo- vaginal, 524 
Thyroid extract, 103, 104, 522, 640 
Tincture, Churchill's, 107 
of aconite, 293 
of belladonna, 325 
of chlorid of iron, 354 
of cinnamon, 522 

of iodin, 106, 107, 337, 353, 597, 641, 
648, 760 
and carbolic acid, 107 
and creasote, 214 
of nux vomica, 100, 681 
of opium, 325 
Tobacco smoking for pruritus, 300 
Toilet of the peritoneum, 91, 848 
Torsion of the pedicle, 817, 835, 840 

of the uterus, 454 
Touch, employment of, 28 
bimanual, 35 

information afforded by, 7,3, 34 
simple, 32 
Trachelorrhaphy, 216 
Transversus perinei muscle, 127 
Traumatism, cause of inflammation, 

of retroversion, 458 
Traumatisms, causes productive of, 

207 
general consideration of, 207 
injuries of the genital organs, 207 

treatment of, 208, 209 
Trays, instrument, 841 
Treatment for absent vagina, 190 
for acute inflammatory difficulties, 

106 
for Bartholinitis, 297 
for carcinoma of the bladder, 598 

of the tube, 791 

of the uterus, 722 

of the vulva, 585 
for cellulitis, pelvic, parametritis or 

periuterine phlegmon, 393 
for chorioepithelioma, 772 
for chronic pelvic troubles, 109 
for cystitis, 324 

acute, 326 

chronic, 327 



Treatment for cystitis, gonorrheal, 326 
for cysts of the vagina, 587 
for defects of clitoris, 199 
for displacements, anteflexion, 463, 

497 

anteversion, 456, 497 

appendages, 514 

lateral flexion, 497 

retroflexion, 473, 497 

retroversion, 473, 497 
for echinococcus cysts, 794 
for edema of vulva, 295 
for elephantiasis vulvas, 580 
for endocervicitis, chronic cervical 

catarrh, cervical endometritis, 336 
for epispadias, 205 
for epithelioma of vagina, 590 
for erectile or vascular tumors of the 

vulva, 576 
for extrauterine pregnancy, 559 
for fibroid tumors and polypi of 

vagina, 588 
for fibromyomatous tumors of the 

uterus, 637 
for fistula, 224 
for gangrene of vulva, 295 
for gas cysts of vulva, 574 
for hematocolpometrosalpinx, 195 
for hematocolpos, 195 
for hematometra, 195 
for hematosalpinx, 195 
for hematuria , 519 
for hemorrhage, genital, 522 

periuterine, 531 
for hydatid cysts of uterus. See 

Chorioepithelioma. 
for injuries of the body of the uterus, 
211 

of the cervix uteri, 214 
for internal hemorrhage, 10 1 
for inversion of the uterus, 507 
for kraurosis vulvae, 301 
for lacerations of pelvic floor, 220 
for liquid cysts of the vulva, 574 
for metritis and endometritis, acute, 
344 
chronic, 353, 360 
for mucous polypi of bladder, 593 

of uterus, 684 
for myoma of bladder, 593 
for oophoritis, 379 
for ovarian tumors, 838 
for papillomata or condylomata, 578 
for perioophoritis, 403 
for perisalpingitis, 403 
for peritonitis, pelvic, parametritis, 

perisalpingitis, or perioophoritis, 

403 
for physometra, 683 
for pruritus vulvae, 299 
for salpingitis. See sec. 390 
for sarcoma of bladder, 593 

of tubes, 793 



896 



INDEX. 



Treatment for sarcoma of uterus, 787 

of vagina, 590 

of vulva, 585 
for shock, 10 1 
for tympanites, 100 
for ureteritis, acute, 329 

chronic, 329 
for urethritis ,315 

acute catarrhal, 315 

chronic catarrhal, 315 
for vaginal hematoma or thrombus, 

525 . . 
tor vaginismus, 302 
for vaginitis, 309 

senile, 309 

specific, 309 
for villous polypi of bladder, 593 
for vulvar hematoma or hematocele, 

for vulvitis, 293 
general, 102 
medical, 102 
post-operative, 97 
Trendelenburg posture, 594, 851 
Triangular ligament, 130 
Trichiasis, 298 
Trigone, 156 
Trional, 299 
Triticum repens, 326 
Trocars, 71, 841 
Tubal abortion, 539 

ostia, accessory, 188 
Tubes, Fallopian, absent or rudimen- 
tary, 188 
accessory tubal ostia, 188 
anomalies in length of, 188 
irrigating, 81 
malformations of, 188 
Tubo-ovarian cysts, 376, 800 
Tumors, benign, 571 

bladder, carcinoma, 597 
myoma, 591 
polypi, mucous, 591 
villous, 590 
broad ligament, carcinoma, 795 
echinococcus, 794 
fibroma, 795 
lipomata, 795 
parovarian varicocele, phlebo- 

liths, 795 
sarcoma, 795 
desmoid, 825 

extrauterine pregnancy, 533 
Fallopian tubes, 789 
carcinoma, 791 
chorioepithelioma, 770 
dermoid, 790 
enchondromata, 790 
fibrocyst, 789 
fibroma or myoma, 789 
hematosalpinx, 195 
hydatid of Morgagni, 790 
hydrosalpinx, 372 



Tumors, Fallopian tubes, lymphangi- 
ectasia, 790 
lymphangiectatic cysts, 790 
papillomata, 791 
pyosalpinx, 630 
sarcoma, 792 
serous, 790 
fecal, 824 
fibrocystic, 114 
genital, 571 

intraligamentary, 555, 816, 817 
malignant, 571 
ovarian, 796 

cystic, areolar, 806 

cysts of corpus luteum, 800 

dermoid, 810 

glandular proliferating cystoma, 

801 
hydatid of Morgagni, 798 
intraligamentary, of ovary and 

uterus, 520 
multilocular, 806 
papillary cystadenoma, 807 

proliferous, 809 
parovarian, 811 
proligerous, 801 
sessile, 802 
solid, 812 

carcinoma, 814 
endothelioma, 814 
fibromyoma, 812 
gyroma, 813 
residual, 798 
retroperitoneal, 834 
sarcoma, 813 

carcinomatosum, 814 
teratoma, 811, 836 
tubo-ovarian, 376, 800 
unilocular, 806 
uterine, carcinoma, 598, 628, 686 
enchondroma, 628 
fibrocystic, 114, 625 
fibromyomata, 599 

interstitial, mural or centric 
fibroids, 606 
myocarcinoma, 628 
myochondroma, 628 
myosarcoma, 628 
osteoma, 628 
puerperal, 683 

hematometra, 683 
hydatid cysts, 684 
hydrometra, 683 
mucous polypi, 684 
physometra, 683 
sarcoma, 628 
submucous fibroids, 603 
subperitoneal growths, 607 
vaginal, cysts, 586 

fibroid tumors and polypi, 587 
malignant neoplasms, 588 
papillomata, 588 
vulvar, 572 



INDEX. 



897 



Tumors, vtdvar, cysts, blood, 574 
gas, 572 
liquid, 574 

gland of Bartholin, 574 
hydrocele, 574 
sebaceous cysts, 574 
simple, 578 
elephantiasis, 580 
enchondroma, 582 
epithelioma, 582 
erectile or vascular, 575 
fibroma, 581 
lipoma, 582 
myxoma, 581 

papillomata or condylomata, 57I 
sarcoma, 582 
Tunica albuginea, 150 
fibrosa, 151 
propria, 151 
Turpentine, 640 
Tympanites, 100, 681, 788, 825 
Tyrosin in cysts, 838 



Ultraviolet rays, 117 
Unilocular cysts, 806 
Urachus, open, 206 
Urea in cysts, 838 
Uremia, 23, 685, 708, 840 
Ureter, accessory, 206 
cancer of, 696, 708 
catheterization of, 65 
description of, 156 
disease of, 298 

cause of pruritus, 298 
exploration of, 64 
inclusion of, in fistulae operations, 

244 
injury of, 667, 852 
irregular exit of, 206 
ligament of, 156 
palpation of, 66 

transplantation of, into bladder, 744 
into rectum, 205 
Ureteritis, 328 
acute, 328 

symptoms of, 328 
causes of, 328 
chronic, 328, 329 

symptoms and signs of, 329 
treatment of, 329 
Uretero vaginal -ureterocervical fistulae, 

239 
Urethra, 153 
absent, 203 
attachments of, 153 
cysts of, 574 
diameter of, 153 
dilatation, 64 
dimensions of, 153 
external meatus, 153 
57 



Urethra, follicular inflammation, 312 
treatment, 317 
granular erosion of, 315 

treatment, 316 
hyperemia of, 311 

use of catheter in, 311 
inflammation of, 64 
length of, 153 
mucous membrane of, 154 
ulceration of, 313 
symptoms, 313 
Urethral caruncle, 32, 312, 575 
endoscope, 64 
specula, 65 
Urethritis, 310 

acute catarrhal, 311, 312 
diagnosis, 312 
symptoms, 312 
chronic interstitial, 311, 312 

s3''mptoms, 312 
follicular, 311, 312 
symptoms of, 313 
treatment of, 317 
gonorrheal, 314 
treatment, 315, 316 
varieties, 310 
Urethrocele. 452, 58 7 
Urethro-vaginal fistula, 221, 236 
Urine, examination of, 79 

diminution of, from pressure of 

ttunor, 816 
incontinence of, 320 
of separate kidneys, 320 
retention of, 318 
Urogenital sinus, 119, 203 
Uteri, accessory, or trifid, 188 
Uterine body, carcinoma of, 696 

cavity, antisepsis of cervix and, 82 
m3^omata, electricity in, 114 
polypi, 24 
Utero-rectal culdesac, 160 
Uterus, absent, 185 
accessory or trifid, 188 
anteflexion of, 426, 459. See Ante- 
flexion. 
anteversion of, 454. See Ante- 
version. 
ascent of, 426 

diagnosis of, 427 
axis of, 173 
bicomis, 182 
arcuatus, 182 
unicollis, 182 
bifidus, 182 

biforis. 185 . . 

bilobularis, 182 
bipartitus, 186 
cancer of, 27, 598 

carcinoma of, 597, 686. See Car- 
cinoma. 
descent or prolapse of, 428 
didelphys, 182 
dilatation of, 48 



898 



INDEX. 



Uterus, dilatation of, gradual, 51 
dimensions of, 140 
dislocation of, 453 
anteposition, 453 
latero-position, 453 
retroposition, 453 
displacements, 425 

classification of, 425 
divisions of, 140 
double, 182 
fetal, 186 
fibromyomatous tumors of (m3^o- 

mata), 599. See Myomata. 
fixation and traction upon, 47 
forces sustaining, 421 
hydatid cysts of, 684 
cystic mole, 684 
incarceration of retrofiexed gravid, 

322 
infantile, 186 
inflammation of, 330 
acute, 339 

causes of, 334 
chronic, 331, 348 

areolar hyperplasia, 334 
cervical catarrh, 331 
diagnosis, 335 

differential, from en- 
dometritis, 336 
from follicular ero- 
sion, 333 
from ovules of Na- 

both, 335 
from papillary ero- 
sion, 332 
from vaginal inflam- 
mation, 335 
symptoms, 334 
classification of, 330 
complicated with retroflexion, 334 
diagnosis of, 335 
diphtheric, 331 
gonorrheal, 331 
micro-organisms, 331 
physical signs of, 335 
prognosis of, 336 
relief of congestion in, 336 
saprophytic, 331 
septic, 331 
symptoms of, 334 
syphilitic, 331 
treatment of, 2,2>^ 
constitutional, 336 
curet, 339 
douches, 336 
electricity, 339 
local, 336 
Paquelin's cautery in chronic 

cases of, 338 
Schroder's operation in, 339 
tampons, 338 
tubercular, 331 
injuries of the body, 210 



Uterus, injuries of the body, treat- 
ment, 211 
inversion of, 500 
extravaginal, 501 
intrauterine, 501 
intra vaginal, 501 
invagination, 501 
lateral flexion of, 496. See Flexion. 
ligaments of, 173 
malignant tumors of, 685 
carcinoma, 686 

adenocarcinoma of body,' 696 
adenomatosum, 689 
chorioepithelioma, 686, 770 
classification of, 686 
endothelioma, 686, 772 
epithelioma, 687 
limit between benign and, 685 
metritis, 339. See Metritis. 
mucous membrane of, 143 
polypi of, 684 

confounded with fibroid polypi, 

684 
treatment of, 685 
normal position of, 422 » 

pathologic changes and what con- 
stitute, 424 
causes of, 424, 425 
physiologic movements of, 421 

influence of distended bladder 
on, 422 
polypus, placental, 685 
position of, 140 
prolapsus of, 428 
puerperal tumors, 683 
hematometra, 683 
hy drome tra, 683 
mucometra, 683 
physometra, 683 
pyometra, 683 
retroflexion of, 426. See Retro- 
flexion. 
retroversion ,457. See Retroversion . 
rudimentary, 185 
rupture of, 51, 211 
sarcoma, 686, 783. See Sarcoma. 
subinvolution of, 455, 470 
unequal development of two sides 

of, 183 
unicornis, 184 
weight of, 140 



Vagma, 133, 586 

absent, treatment of, 190 
anterior fornix of, 137 
atresia of, 194 

changes caused by pregnancy, 138 
closure of vesico-vaginal fistula, 225 
complete absence or rudimentary 
development of, 189 



INDEX. 



899 



Vagina, cysts of, 572, 586 
diagnosis, 587 

differential, from cystocele or 
urethrocele, 587 
origin, 586 
symptoms, 587 
treatment, 587 
dimensions of, 134 
double, 193 
epithelioma of, 588 
fibroid tumors and polypi of, 587 
diagnosis, 587 

differential, from malig- 
nant disease, 588 
symptoms, 587 
treatment, 588 
enucleation, 588 
lacerations of, 220 
lymphatics of, 139, 304 
malignant neoplasms, 588 
etiology of, 588 
symptoms, 589 
treatment, 590 
microscopic section of wall of, 138 
mucous membrane of, 138 

secretion of, 138 
nerves, 140, 304 
papillomata of, 588 
posterior fornix of, 137 
prolapsus, or inversion of, 428 
rudimentary, 189 
rugae of, 135, 137, 138, 139 
tumors of, 587 
unilateral, 193 
wall of, 138 
Vaginal enterocele, 439 
hysterectomy, 657, 729 
irrigation, 102 
orifice, 121 

section, 412. See Section, vaginal. 
sphincter, 138 

wall, excision of anterior, for cysto- 
cele, 449 
Vaginismus, 23, 24, iii, 115 
cause of pain in, 24 
causes of, 301 
prognosis of, 302 
superior, 302 
symptoms, 302 
treatment, 302 
Vaginitis, colpitis, or elytritis, 304 
auto-infection, 305 
bacterial forms of secretion, 305 
diagnosis, 308 
etiology, 305, 307 
pathology, 306 
of simple, 306 
of specific, 306 
prognosis, 309 
symptoms, 308 
synonyms of, 304 
treatment, 309 
varieties, 306 



Vaginitis, varieties, diphtheric, 306 

emphysematous, 306 

exfoliative, 306 . 

phlegmonous, 306 

senile, 306 

simple, 306 

specific, 306 
Valve of Houston, 157 
Varicocele, parovarian, phleboliths, 

795 
Vascular supply of pelvic organs, 163 
Vaselin, 761 
Veins, internal iliac, 169 

plexus of hemorrhoidal, 166 

left ovarian, 168 

ovarian, 167, 169 

pampiniform plexus, 169 

right ovarian, 167 

superficial abdominal enlarged by 
pressure, 68 

uterine, 167 

vaginal, 167 

vesical plexus, 167 
Venereal warts or sores, 32 
Ventral hernia, 68 

Ventrofixation of uterus, 491, 500, 
516 
advantages and disadvantages of, 

493 
Ventrosuspension of uterus, 491, 500 
Version, lateral, 459 
Vertigo, obstinate, 660 
Vesical douches, 106 

reflexes, 23 

tenesmus, 616 
Vesico-abdominal pouch, 161 
Vesico-urethral fissure, 314 
Vesico-uterine culdesac, 160, 161 
Vesico-uterine fistula, 221, 236 
Vesico-utero-vaginal fistula, 238 
Vesico-vaginal fistula, 225 
Vestibule, 124 

bulb of, 129 
Viburnum prunifolium, 103 
Virgins, examination of, 36 
Viscera, inflammation of pelvic, 114 
Visceral injuries during operations, 

851 
Volvulus, 854 
Vomiting, 99, 636, 681 

following operation, 681 

in cancer, 766 

obstinate, 99 

rectal feeding in, 100 

remedies for, 99 

rupture of cyst by, 821 

stomach tube for, 100, 681 
Vulva, 121 

absence of, 198 

changed relations of structures of, 
421 

edema of, 295, 580 

eruptive diseases of, 291 



900 



INDEX. 



Vulva, eruptive diseases of, causes of, 
291 
eczema of, 291 
erysipelas of, 291 
herpes of, 291 
gangrene of, 295 
infantile, 198 
kraurosis, 300 
neuroma, 577 

treatment of, 578 
pruritus, 298 

syphilitic hypertrophy, 295 
tumors, 572 

benign, classification of, 572 
cysts, 572 
' blood, 574 
gas, 572 
liquid, 572, 574 
hydrocele, 574 

differential diagnosis from 
hernia, 574 
of glands of Bartholin, 574 
of hymen, 574 
of urethra, 574 
sebaceous, 574 
elephantiasis, 580 
diagnosis of, 580 
forms of, 580 
symptoms of, 580 
enchondroma, 582 
treatment of, 574 
erectile or vascular, 575 
diagnosis of, 576 
etiology, 576 
symptoms, 576 
treatment, 576 
urethral caruncle, 575 
fibroma and myxoma, 581 
lipoma, 582 
malignant, 582 

adenocarcinoma, 582 
epithelioma, 582 
sarcoma, 582 
solid, 572, 580 
neuroma, 577 
simple vegetations, 578 
condylomata, 578 
papillomata, 578 
treatment of, 578 
varicose veins of, 577 
Vulvar atresia, 194 
Vulvitis, 288 

chancroidal, 289 
diagnosis of, 292 
diphtheric, 288, 292 



Vulvitis, eruptive, 288, 291 
follicular, 288, 289 
gonorrheal, 286, 289 
herpetic, 291 
phlegmonous, 288, 292 
simple or catarrhal, 288, 289 

pruritus a symptom. 289 
syphilitic, 289 
treatment of, 293 
venereal, 288, 289 
causes of, 288 
Vulvo-vaginal glands, 129 
inflammation of, 295 
Vulvo-vaginitis in young girls, 303. 

304 
dangers of, 304 
treatment, 304 



W. 

Water, alkaline, 325 

Buffalo lithia, 325 

Carlsbad, 325, 361 

Friederichshail, 102, 361 

Hunyadi Janos, 102, 361 

Londonderry lithia, 325 

mineral, 361, 638 

Saratoga, 325 

Seawright, 325 

Seltzer, 325 

sterilized, 88 

Vichy, 325 
Whiskey, 100, 405, 681 
White line of Farre, 149 
Wolffian body, 118,' 153, 811 

duct, 118 
Wound, closure of, 95 

dressing, 96 

methods of suturing, 95 

post-operative treatment of, 97, 730 



Zinc alum sticks, 338 

chlorid, 108, 214, 310, 353, 724, 730 
crayons, 108 
solution, 297 
sticks, 761 
sulphate, 108, 522 

crayons, 108 
valerianate, 103 
Zingiber, syrup, 682 
Zona pellucida, 151 
Zynol, 326 



OCT 13 1903 



